Compositions of obeticholic acid and methods of use

ABSTRACT

The disclosure relates to obeticholic acid formulations with improved stability, dissolution, and/or solubility, methods of preparing the same for use and methods of treating various diseases and conditions.

BACKGROUND

The farnesoid X receptor (FXR), also known as the bile acid receptor(BAR) or NR1H4, is a member of the nuclear receptor superfamily ofligand-activated transcription factors. FXR forms with retinoid Xreceptor (RXR) a heterodimer receptor crucial for bile acid homeostasis.FXR is expressed in various tissues including the liver, kidney,intestine, colon, ovary, and adrenal gland, and is activated by avariety of naturally occurring bile acids, including the primary bileacid chenodeoxycholic acid (CDCA) and its taurine and glycineconjugates. Upon activation, the FXR-RXR heterodimer binds the promoterregion of target genes and regulates their expression.

6-Ethyl-chenodeoxycholic acid (6-ECDCA, or obeticholic acid, or OCA), abile acid derivative, shows a potent FXR activating activity, andaccordingly offers great promise for the treatment of FXR-mediateddiseases or conditions. Thus, there is a need to develop obeticholicacid compositions having desirable dissolution profile and solubility,and possessing advantageous storage stability.

SUMMARY

The present disclosure relates to novel formulations of obeticholicacid, an FXR agonist, with improved stability, dissolution, andsolubility, methods of preparing the same and methods of using the novelformulations for treating a disease or condition. In certain instances,the disease or condition is primary biliary cirrhosis (PBC), also knownas primary biliary cholangitis. In other instances, the disease orcondition is primary sclerosing cholangitis (PSC), chronic liverdisease, nonalcoholic fatty liver disease (NAFLD), nonalcoholicsteatohepatitis (NASH), hepatitis C infection, alcoholic liver disease,liver damage due to progressive fibrosis, or liver fibrosis. In anotherinstance, the disease is NASH. In still other instances, the disease orcondition is solid-tumor cancer such as, for example, hepatocellularcarcinoma (HCC), colorectal cancer, gastric cancer, liver cancer, breastcancer, kidney cancer, or pancreatic cancer. Further provided herein arenovel dosing regimens for administration of obeticholic acid fortreatment of the diseases or conditions described herein.

A first aspect of the disclosure relates to a composition comprisingobeticholic acid, or a pharmaceutically acceptable salt, ester, or aminoacid conjugate thereof, wherein obeticholic acid or a pharmaceuticallyacceptable salt, ester, or amino acid conjugate thereof is in the formof particles, and wherein at least 50% of the particles have a diameterof less than 200 μm. Such compositions include all those describedherein.

Another aspect of the disclosure relates to treating a disease orcondition described herein in a patient in need thereof by administeringa composition that includes obeticholic acid, or a pharmaceuticallyacceptable salt, ester, or amino acid conjugate thereof, where theobeticholic acid or a pharmaceutically acceptable salt, ester, or aminoacid conjugate thereof is in the form of particles.

Another aspect of the disclosure relates to treating a disease orcondition described herein in a patient in need thereof by administeringa composition that includes obeticholic acid, or a pharmaceuticallyacceptable salt, ester, or amino acid conjugate thereof, where theobeticholic acid or a pharmaceutically acceptable salt, ester, or aminoacid conjugate thereof is in the form of particles, and wherein at least50% of the particles have a diameter of 200 μm or less.

Another aspect of the disclosure relates to treating primary biliarycirrhosis (PBC) in a patient in need thereof by administering acomposition that includes obeticholic acid, or a pharmaceuticallyacceptable salt, ester, or amino acid conjugate thereof, optionally in atitration period, where the obeticholic acid or a pharmaceuticallyacceptable salt, ester, or amino acid conjugate thereof is in the formof particles, and wherein at least 50% of the particles have a diameterof 200 μm or less.

In still another aspect of the disclosure is a method of treatingprimary sclerosing cholangitis (PSC), chronic liver disease,nonalcoholic fatty liver disease (NAFLD), nonalcoholic steatohepatitis(NASH), hepatitis C infection, alcoholic liver disease, liver damage dueto progressive fibrosis, or liver fibrosis in a patient in need thereofby administering a composition that includes obeticholic acid, or apharmaceutically acceptable salt, ester, or amino acid conjugatethereof, optionally in a titration period, where the obeticholic acid ora pharmaceutically acceptable salt, ester, or amino acid conjugatethereof is in the form of particles. In one example, at least 50% of theparticles have a diameter of 200 μm or less.

In yet another aspect of the disclosure is a method of treating asolid-tumor cancer in a patient in need thereof by administering acomposition that includes obeticholic acid, or a pharmaceuticallyacceptable salt, ester, or amino acid conjugate thereof, optionally in atitration period, where the obeticholic acid or a pharmaceuticallyacceptable salt, ester, or amino acid conjugate thereof is in the formof particles. In one example, at least 50% of the particles have adiameter of 200 μm or less.

In another aspect of the disclosure is a method of treating anautoimmune disease in a patient in need thereof by administering acomposition that obeticholic acid, or a pharmaceutically acceptablesalt, ester, or amino acid conjugate thereof, optionally in a titrationperiod, where the obeticholic acid or a pharmaceutically acceptablesalt, ester, or amino acid conjugate thereof is in the form ofparticles. In one example, at least 50% of the particles have a diameterof 200 μm or less.

In another aspect of the disclosure are methods of treating a disease orcondition described herein by administering a obeticholic acidcomposition described herein where the obeticholic acid composition isadministered as part of a treatment regimen that includes a titrationperiod and a starting dose of the obeticholic acid composition at anamount of about 5 mg or 10 mg. In particular instances, such methodsinclude daily (QD) administration of an obeticholic acid describedherein during the titration period. In particular instances, suchmethods also include administration of an adjusted dose of anobeticholic acid composition described herein after the titrationperiod.

Another aspect of the disclosure relates to a composition comprisingobeticholic acid, or a pharmaceutically acceptable salt, ester, or aminoacid conjugate thereof, wherein obeticholic acid or a pharmaceuticallyacceptable salt, ester, or amino acid conjugate thereof is in the formof particles, and wherein at least 50% of the particles have a diameterof less than 200 μm. Another aspect of the disclosure relates to acomposition comprising obeticholic acid, or a pharmaceuticallyacceptable salt, ester, or amino acid conjugate thereof, and apharmaceutically acceptable excipient (e.g., sodium starch glycolate)having a low alcohol (e.g., ethanol or methanol) content (e.g., lessthan 5% (wt/wt)).

In another aspect, the disclosure relates to a pharmaceuticalcomposition, comprising a therapeutically effective amount ofobeticholic acid, or a pharmaceutically acceptable salt, ester, or aminoacid conjugate thereof, in the form of particles, and a pharmaceuticallyacceptable excipient (e.g., sodium starch glycolate) having a lowalcohol (e.g., ethanol or methanol) content (e.g., less than 5%(wt/wt)), wherein at least 50% of the particles have a diameter of lessthan 200 μm.

Another aspect of the disclosure relates to a pharmaceuticalcomposition, comprising obeticholic acid, or a pharmaceuticallyacceptable salt, ester, or amino acid conjugate thereof, in the form ofparticles, wherein at least 50% of the particles have a diameter of lessthan 200 μm, at about 1% to about 6% by weight, sodium starch glycolateat about 2% to about 8% by weight having a low alcohol (e.g., ethanol ormethanol) content (e.g., less than 5% (wt/wt)), a lubricant (e.g.,magnesium stearate) at about 0.1% to about 2.0% by weight, and a diluent(e.g., microcrystalline cellulose) at about 85% to about 95% by weight.

In another aspect, the disclosure relates to a method for preparing acomposition comprising obeticholic acid, or a pharmaceuticallyacceptable salt, ester, or amino acid conjugate thereof, in the form ofparticles, wherein at least 50% of the particles have a diameter of lessthan 200 μm, comprising forming the particles through jet-milling.

Another aspect of the disclosure relates to a tablet comprising anintra-granular portion and an extra-granular portion, the intra-granularportion comprising obeticholic acid, or a pharmaceutically acceptablesalt, ester, or amino acid conjugate thereof, microcrystallinecellulose, and one or more additional pharmaceutical excipients, and theextra-granular portion comprising one or more pharmaceutical excipients.

Another aspect of the disclosure relates to a tablet comprising anintra-granular portion and an extra-granular portion, the intra-granularportion comprising obeticholic acid, or a pharmaceutically acceptablesalt, ester, or amino acid conjugate thereof, microcrystallinecellulose, and one or more additional pharmaceutical excipients, and theextra-granular portion comprising microcrystalline cellulose and one ormore additional pharmaceutical excipients.

In another aspect, the disclosure relates to methods for treating orpreventing an FXR mediated disease or condition or a disease orcondition in which elevated concentrations of circulating lipidcompounds or glucose in the blood, or decreased insulin level, orincreased insulin resistance is involved, or inhibiting or reversingfibrosis, comprising administering a therapeutically effective amount ofa composition of the present disclosure to a subject in need thereof.

Another aspect of the disclosure relates to use of a composition of thepresent disclosure for treating or preventing an FXR mediated disease orcondition or a disease or condition in which elevated concentrations ofcirculating lipid compounds or glucose in the blood, or decreasedinsulin level, or increased insulin resistance is involved, or forinhibiting or reversing fibrosis.

In another aspect, the disclosure relates to use of a composition of thepresent disclosure in the manufacture of a medicament for treating orpreventing an FXR mediated disease or condition or a disease orcondition in which elevated concentrations of circulating lipidcompounds or glucose in the blood, or decreased insulin level, orincreased insulin resistance is involved, or for inhibiting or reversingfibrosis.

The compositions and methods of the present disclosure address unmetneeds in the treatment or prevention of an FXR mediated disease or adisease or disorder in which elevated concentrations of circulatinglipid compounds in the blood such as cholesterol and triglycerides orglucose are involved.

The compositions and methods of the present disclosure address unmetneeds in the treatment of diseases and conditions described herein,including for example, PBC, PSC, NAFLD, NASH, cancer, and autoimmunediseases described herein.

BRIEF DESCRIPTION OF THE DRAWINGS

FIG. 1 is a particle size distribution histogram of obeticholic acidbefore jet-milling.

FIG. 2 is a particle size distribution histogram of obeticholic acidafter jet-milling.

FIG. 3 is a graph showing the dissolution profile of 10 mg tabletscontaining unmilled/non-agglomerated, unmilled/agglomerated, orjet-milled obeticholic acid.

FIG. 4 is a graph showing the dissolution profile of 5 mg tabletscontaining unmilled or jet-milled obeticholic acid.

FIG. 5 is a graph showing solubility of obeticholic acid in variousbuffers at 37° C. over a pH range of about 1.2 to about 12. The dashedand dotted lines represent the Biopharmaceutical Classification System(BCS) limit for 5 mg and 10 mg doses, respectively (5 and 10 mg/250 mL)

FIG. 6 is a graph showing obeticholic acid solubility in variousbiologically relevant buffers over a pH range of about 1.2 to about 12.The dashed and dotted lines represent the BiopharmaceuticalClassification System (BCS) high-solubility limit for 5 mg and 10 mgdoses, respectively (5 and 10 mg/250 mL).

FIG. 7A shows the LC/HRMS spectrum in the positive mode of a sample ofobeticholic acid OCA and the synthesized ethyl ester of obeticholic acidOCA. FIG. 7B shows the mass spectrum in the positive mode of a sample ofobeticholic acid OCA and the synthesized ethyl ester of obeticholic acidOCA.

FIG. 8A shows the total ion count (TIC) chromatogram in the positive ionmode acquired on Q-TOF LC/MS of a sample of obeticholic acid OCAcontaining the PEG impurity, FIG. 8B shows the mass spectra in thepositive mode acquired on Q-TOF LC/MS of a sample of obeticholic acidOCA containing the PEG impurity. FIG. 8C shows the total ion count (TIC)chromatogram acquired on triple quad (QQQ) mass spectrometer of a sampleof obeticholic acid OCA containing the PEG impurity.

FIG. 9 shows an enlarged spectrum of the co-eluting peaks containingobeticholic acid OCA and the PEG impurity displaying spacingcharacteristics of PEG.

FIG. 10 illustrates the percent Change in ALP levels from Baseline toEOS: mITT Population (N=161).

FIG. 11 illustrates ALP Concentration (U/L) over duration of treatment.

FIG. 12 illustrates TB Concentration (μmol/L) over duration oftreatment.

FIG. 13 illustrates proposed metabolic pathways of OCA in human plasma.

FIG. 14 illustrates Observed Individual Patient-Level Change in ALP fromBaseline at Month for responders and non-responders by treatment group(Placebo (FIG. 14A), for OCA titration (FIG. 14B) and for OCA 10 mg(FIG. 14C)).

FIG. 15A illustrates mean ALP over time and FIG. 15B illustrates meantotal bilirubin (TB) over time.

FIG. 16 illustrates the mean plasma concentration-time profile(Semi-log) of total OCA following a single oral dose of 10 mg OCA (insetshows expanded view of first 24 hours).

FIG. 17A illustrates ALP levels and FIG. 17 B illustrates change in ALPfrom baseline with OCA monotherapy and combination therapy with UDCA,based on pooled data from study 747-201, study 747-202 and Phase 3 study747-301.

FIG. 18 illustrates the Goodness of Fit: Observed Concentrations vsPredicted Concentrations of OCA. FIG. 18A shows the individual glyco-OCAgroup, FIG. 18B shows the individual unconjugated OCA group, FIG. 18Cshows individual tauro-OCA group, FIG. 18D shows the populationglyco-OCA group, FIG. 18E shows the population unconjugated OCA group,and FIG. 18F shows the population tauro-OCA group.

FIG. 19 illustrates the Goodness of Fit: Residuals. FIG. 19A shows theglyco-OCA group vs. concentration, FIG. 19B shows the unconjugated OCAgroup vs. concentration, FIG. 19C shows the tauro-OCA group vs.concentration, FIG. 19D shows the glyco-OCA group vs. time, FIG. 19Eshows the unconjugated OCA group vs. time, and FIG. 19E shows thetauro-OCA group vs. time.

FIG. 20 illustrates External Validation of Model in Subjects with NormalHepatic Function. FIG. 20A shows the single dose of 5 mg OCA, FIG. 20Bshows the single dose of 10 mg OCA, FIG. 20C shows the single dose of 25mg OCA, FIG. 20D shows the multiple dose of 5 mg OCA, FIG. 20E shows themultiple dose of 10 mg OCA, and FIG. 20F shows the multiple dose of 25mg OCA.

FIG. 21 illustrates External Validation of Model in Subjects with NormalHepatic Function. FIG. 21A shows the 6 day profile in Period 1, FIG. 21Bshows the 24 hour profile in Period 1, FIG. 21C shows the 6 day profilein Period 2, and FIG. 21D shows the 24 hour profile in Period 2.

FIG. 22 illustrates External Validation of Model in Patients withImpaired Hepatic Function. FIG. 22A shows the effect of 10 mg OCA inmild impairment, FIG. 20B shows the effect of 10 mg OCA in moderateimpairment, FIG. 20C shows the effect of 10 mg OCA in severe impairment,FIG. 22D shows the effect of 25 mg OCA in mild impairment, FIG. 20Eshows the effect of 25 mg OCA in moderate impairment, and FIG. 20E showsthe effect of 25 mg OCA in severe impairment.

FIG. 23A and FIG. 23B illustrates plasma OCA Concentrations are a PoorSurrogate for Liver OCA Concentrations.

FIG. 24A, FIG. 24B, and FIG. 24C illustrate changes in FIG. 4, APRIScore, and NFS during the course of treating NASH using the obeticholicacid compositions described herein, respectively. *p<0.05, **p<0.01,***p<0.0001; P-values were calculated using ANCOVA models, regressingchange from baseline at each post-baseline visit on treatment group andbaseline value of the outcome.

FIG. 25 illustrates a Visual Predictive Check of PK Model in Subjectswith Normal Hepatic Function where FIG. 25A shows a 6-day profile, FIG.25B shows a 24-hour profile, FIG. 25C shows a 6-day profile over period2 and FIG. 25D shows a 24-hour profile over period 2.

FIG. 26 shows Visual Predictive Check of PK model in Patients withNormal and Impaired Hepatic Function where FIG. 26A shows normalfunction, FIG. 26B shows mild impairment, FIG. 26C shows moderateimpairment and FIG. 26D shows severe impairment.

FIG. 27 shows External Validation of Model in Subjects with NormalHepatic Function where FIG. 27A shows a single dose of OCA 5 mg, FIG.27B shows a single dose of OCA 10 mg, FIG. 27C shows a single dose ofOCA 25 mg, FIG. 27D shows a multiple dose of OCA 5 mg, FIG. 27E shows amultiple dose of OCA 10 mg, and FIG. 27F shows a multiple dose of OCA 25mg.

FIG. 28 shows External Validation of Model in Patients with ImpairedHepatic Function where FIG. 28A shows mild impairment of OCA 10 mg, FIG.28B shows moderate impairment of OCA 10 mg, FIG. 28C shows severeimpairment of OCA 10 mg, FIG. 28D shows mild impairment of OCA 25 mg,FIG. 28E shows moderate impairment of OCA 25 mg, and FIG. 28F showssevere impairment of OCA 25 mg.

DETAILED DESCRIPTION

Pharmaceutical preparations containing a poorly water-soluble drugrequire some tools for improving the dissolution property of the drug,for example, adding a surfactant or other additive, or amorphizing thedrug. However, the addition of the surfactant or other additive canchemically destabilize the drug, and methods of amorphizing the drug mayrequire changing the crystal form.

When compositions containing a high concentration of a poorlywater-soluble drug are produced, usually, powders are tableted by directcompression or granules are produced by dry or wet granulation methodsand tableted. However, tableting by direct compression and granulationare largely affected by the physical properties of the drug and oftenhave great weight variations and poor content uniformity at the time oftableting, resulting in poor manufacturability in consideration ofproductivity. Moreover, these approaches can provide a drug product withpoor dissolution.

The present application is directed to compositions and formulations ofobeticholic acid, a pharmaceutically active ingredient (also known asINT-747) having the chemical structure:

or a pharmaceutically acceptable salt, ester, or amino acid conjugate(such as, e.g., glycine, taurine or sarcosine conjugate) thereof havingimproved dissolution, solubility, and stability for the treatment of adisease or condition described herein.

The details of the disclosure are set forth in the accompanyingdescription below. Although methods and materials similar or equivalentto those described herein can be used in the practice or testing of thepresent disclosure, illustrative methods and materials are nowdescribed. Other features, objects, and advantages of the disclosurewill be apparent from the description and from the claims. In thespecification and the appended claims, the singular forms also includethe plural unless the context clearly dictates otherwise. Unless definedotherwise, all technical and scientific terms used herein have the samemeaning as commonly understood by one of ordinary skill in the art towhich this disclosure belongs. In the case of conflict, the presentspecification will control. All patents and publications cited in thisspecification are incorporated herein by reference in their entireties.

All percentages and ratios used herein, unless otherwise indicated, areby weight.

The term “viscosity enhancer,” as used herein, refers to an agent or amixture of agents that increases the thickness of a liquid therebykeeping the active ingredient suspended to allow accurate dosing.Viscosity enhancers include, but are not limited to, xantham gum, guargum, acacia, alginic acid, sodium alginate, propylene glycol alginate,povidone, carbomer, salts of carboxymethylcellulose, methylcellulose,ethylcellulose, hydroxyethyl cellulose, hydroxypropyl cellulose,hydroxypropyl methylcellulose, bentonite, polydextrose, carrageenan,sucrose, sorbitol, xylitol, dextrose, fructose, malitol, gelatin,tragacanth, a polyvinyl alcohol, cetearyl alcohol, colloidal silicondioxide and mixtures thereof. In one embodiment, the viscosity enhancercan be any viscosity enhancer known in the art.

The term “flavoring agent,” as used herein, refers to an agent or amixture of agents that adds flavor to a mixture. Flavoring agentsinclude, but are not limited to, artificial strawberry flavor, artbanana flavor and artificial cream flavor. In one embodiment, theflavoring agent can be any flavoring agent known in the art.

The term “preservative,” as used herein, refers to an agent or mixtureof agents that is used to protect a composition against antimicrobial(e.g., yeast, mold, bacteria) activity. Preservatives include, but arenot limited to, sodium benzoate, benzoic acid,ethylenediaminetetraacetic acid, sorbic acid, benzethonium chloride,benzalkonium chloride, bronopol, butyl paraben, methyl paraben,ethylparaben, propyl paraben, thiomerosol, sodium propionate,chlorhexidine, chlorobutanol, chlorocresol, cresol, imidurea, phenol,phenylmercuric salts, potassium sorbate, propylene glycol, and mixturesthereof. In one embodiment, the preservative can be any preservativeknown in the art.

The term “organ” refers to a differentiated structure (as in a heart,lung, kidney, liver, etc.) consisting of cells and tissues andperforming some specific function in an organism. This term alsoencompasses bodily parts performing a function or cooperating in anactivity (e.g., an eye and related structures that make up the visualorgans). The term “organ” further encompasses any partial structure ofdifferentiated cells and tissues that is potentially capable ofdeveloping into a complete structure (e.g., a lobe or a section of aliver).

As used herein the term “6-ethyl chenodeoxycholic acid”, “6-ECDCA”,“obeticholic acid” or “OCA” refers to a compound having the chemicalstructure:

Other chemical names for obeticholic acid include:3α,7α-dihydroxy-6α-ethyl-5β-cholan-24-oic acid,6α-ethyl-chenodeoxycholic acid, 6-ethyl-CDCA, 6ECDCA, cholan-24-oicacid, 6-ethyl-3,7-dihydroxy-(3α,5β,6α,7α)- and INT-747. The CAS registrynumber for obeticholic acid is 459789-99-2. This term refers to allforms of obeticholic acid, e.g., non-crystalline, crystalline andsubstantially pure.

An “obeticholic acid composition” described herein refers to obeticholicacid administered to a patient in any form described herein including asa component of a pharmaceutical composition.

The articles “a” and “an” are used in this disclosure to refer to one ormore than one (i.e., to at least one) of the grammatical object of thearticle. By way of example, “an element” means one element or more thanone element.

The term “and/or” is used in this disclosure to mean either “and” or“or” unless indicated otherwise.

As used herein, the term “purity” refers to a chemical analysis of acompound obtained from, e.g., HPLC. In one embodiment, the purity of acompound is compared to the purity of the reference standard, e.g.,obeticholic acid, via the area under their respective peak forcomparisons. In one embodiment, purity accounts for the organicimpurities in a sample.

“Treating”, includes any effect, e.g., lessening, reducing, modulating,or eliminating, that results in the improvement of the condition,disease, disorder, etc. “Treating” or “treatment” of a disease stateincludes: inhibiting the disease state, i.e., arresting the developmentof the disease state or its clinical symptoms; or relieving the diseasestate, i.e., causing temporary or permanent regression of the diseasestate or its clinical symptoms.

The term “regimen” refers to a protocol for dosing and/or timing theadministration of one or more therapies (e.g., an obeticholic acidcomposition described herein or another active agent such as for exampleUDCA) for treating a disease, disorder, or condition described herein. Aregimen can include periods of active administration and periods of restas known in the art. Active administration periods includeadministration of the obeticholic acid compositions described herein ina defined course of time, including, for example, the number of andtiming of dosages of the compositions. In some regimens, one or morerest periods can be included where no compound is actively administered,and in certain instances, includes time periods where the efficacy ofsuch compounds can be minimal.

The term “enhance” refers to an increase or improvement in the functionor activity of a protein or cell after administration or contacting witha combination described herein compared to the protein or cell prior tosuch administration or contact.

“Preventing” the disease state includes causing the clinical symptoms ofthe disease state not to develop in a subject that may be exposed to orpredisposed to the disease state, but does not yet experience or displaysymptoms of the disease state.

The term “inhibiting” or “inhibition,” as used herein, refers to anydetectable positive effect on the development or progression of adisease or condition. Such a positive effect may include the delay orprevention of the onset of at least one symptom or sign of the diseaseor condition, alleviation or reversal of the symptom(s) or sign(s), andslowing or prevention of the further worsening of the symptom(s) orsign(s).

“Disease state” means any disease, disorder, condition, symptom, orindication.

The term “effective amount” as used herein refers to an amount ofobeticholic acid (e.g., an FXR-activating ligand) that produces an acuteor chronic therapeutic effect upon appropriate dose administration. Theeffect includes the prevention, correction, inhibition, or reversal ofthe symptoms, signs and underlying pathology of a disease/condition(e.g., fibrosis of the liver, kidney, or intestine) and relatedcomplications to any detectable extent.

“A therapeutically effective amount” means the amount of obeticholicacid that, when administered to a mammal for treating a disease, issufficient to effect such treatment for the disease. The“therapeutically effective amount” will vary depending on obeticholicacid, the disease and its severity and the age, weight, etc., of themammal to be treated. A therapeutically effective amount can refer to astarting dose or adjusted dose as set forth herein.

A therapeutically effective amount of obeticholic acid can be formulatedwith a pharmaceutically acceptable carrier for administration to a humanor an animal. Accordingly, obeticholic acid or its formulations can beadministered, for example, via oral, parenteral, or topical routes, toprovide an effective amount of the compound. In alternative embodiments,obeticholic acid prepared in accordance with the present disclosure canbe used to coat or impregnate a medical device, e.g., a stent.

For any compound, the therapeutically effective amount can be estimatedinitially either in cell culture assays or in animal models, usuallyrats, mice, rabbits, dogs, or pigs. The animal model may also be used todetermine the appropriate concentration range and route ofadministration. Such information can then be used to determine usefuldoses and routes for administration in humans. Therapeutic/prophylacticefficacy and toxicity may be determined by standard pharmaceuticalprocedures in cell cultures or experimental animals, e.g., ED50 (thedose therapeutically effective in 50% of the population) and LD50 (thedose lethal to 50% of the population). The dose ratio between toxic andtherapeutic effects is the therapeutic index, and it can be expressed asthe ratio, LD50/ED50. Pharmaceutical compositions that exhibit largetherapeutic indices are preferred. The dosage may vary within this rangedepending upon the dosage form employed, sensitivity of the patient, andthe route of administration.

Dosage and administration are adjusted to provide sufficient levels ofthe active agent(s) or to maintain the desired effect. Factors which maybe taken into account include the severity of the disease state, generalhealth of the subject, age, weight, and gender of the subject, diet,time and frequency of administration, drug combination(s), reactionsensitivities, and tolerance/response to therapy.

A “starting dose” as used herein refers to an initial dose provided to apatient to provide a clinical effect while minimizing onset oroccurrence of an adverse effect. A starting dose can, in certaininstances, be less than an amount typically administered to a patient. Astarting dose is provided in an amount that is titrated or graduallyincreased over the course of a titration period or during the course oftreatment with an obeticholic acid composition described herein.

A “titration period” refers to a length of time for which a startingdose is administered to a patient. A titration period continues for aspecified length of time, where the patient is often monitored for liverfunction and/or liver biochemistry as described herein. In oneembodiment a titration period concludes when a patient tolerates anobeticholic acid composition described herein but has a decreased orminimal reduction in alkaline phosphatase.

An “adjusted dose” as used herein refers to a dose of an obeticholicacid composition described herein administered after the termination ofa titration period. An adjusted dose is often increased compared to astarting dose but, as provided herein, patient tolerance and otherfactors described herein determine the dosage amount of an adjusteddose. A “re-adjusted dose” as used herein refers to any changed dosageamount or dose frequency of an adjusted dose in a patient.

“Hepatic impairment” is used in accordance with its standard meaning(s)in the art and can, in certain embodiments herein refer to scoring basedupon the Child-Pugh Score of A, B, and C.

The term “administering” refers to the act of delivering an obeticholicacid composition described herein into a subject by such routes as oral,mucosal, topical, suppository, intravenous, parenteral, intraperitoneal,intramuscular, intralesional, intrathecal, intranasal or subcutaneousadministration. Parenteral administration includes intravenous,intramuscular, intra-arterial, intradermal, subcutaneous,intraperitoneal, intraventricular, and intracranial administration. Theterm can also refer to the frequency (e.g., daily, weekly, monthly,etc.) of providing an obeticholic acid composition described herein to apatient. Administration generally occurs after the onset of the disease,disorder, or condition, or its symptoms but, in certain instances, canoccur before the onset of the disease, disorder, or condition, or itssymptoms (e.g., administration for patients prone to such a disease,disorder, or condition). In certain embodiments, administration as usedherein refers to oral administration.

The term “co-administration” refers to administration of two or moreagents (e.g., an obeticholic acid composition described herein andanother active agent such as UDCA or an anti-cancer agent describedherein). The timing of co-administration depends in part of thecombination and the compositions administered and can includeadministration at the same time, prior to, or after the administrationof one or more additional therapies. An obeticholic acid composition ofthe instant invention can be administered alone or can be coadministeredto the patient. Co-administration is meant to include simultaneous orsequential administration of an obeticholic acid compositionindividually or in combination (more than one compound or agent). Thus,the preparations can also be combined, when desired, with other activesubstances (e.g., to reduce metabolic degradation). The obeticholic acidcompositions described herein can be used in combination with each other(i.e., two different obeticholic acid compositions), with other activeagents known to be useful in treating a disease, or with adjunctiveagents that are not effective alone, but can contribute to or enhancethe efficacy of the active agent.

The term “anti-cancer agent” is used in accordance with its plainordinary meaning and refers to a composition having anti-neoplasticproperties or the ability to inhibit the growth or proliferation ofcells. In embodiments, an anti-cancer agent is a chemotherapeutic agent.In embodiments, an anti-cancer agent is an agent identified hereinhaving utility in methods of treating cancer. In embodiments, ananti-cancer agent is an agent approved by the FDA or similar regulatoryagency of a country other than the USA, for treating cancer.

“Pharmacological effect” as used herein encompasses effects produced inthe subject that achieve the intended purpose of a therapy. In oneembodiment, a pharmacological effect means that primary indications ofthe subject being treated are prevented, alleviated, or reduced. Forexample, a pharmacological effect would be one that results in theprevention, alleviation or reduction of primary indications in a treatedsubject. In another embodiment, a pharmacological effect means thatdisorders or symptoms of the primary indications of the subject beingtreated are prevented, alleviated, or reduced. For example, apharmacological effect would be one that results in the prevention orreduction of primary indications in a treated subject.

“Geometric Isomers” means the diastereomers that owe their existence tohindered rotation about double bonds. These configurations aredifferentiated in their names by the prefixes cis and trans, or Z and E,which indicate that the groups are on the same or opposite side of thedouble bond in the molecule according to the Cahn-Ingold-Prelog rules.

“Solvates” means solvent addition forms that contain eitherstoichiometric or non-stoichiometric amounts of solvent. Obeticholicacid may have a tendency to trap a fixed molar ratio of solventmolecules in the crystalline solid state, thus forming a solvate. If thesolvent is water the solvate formed is a hydrate, when the solvent isalcohol, the solvate formed is an alcoholate. Hydrates are formed by thecombination of one or more molecules of water with one of the substancesin which the water retains its molecular state as H₂O, such combinationbeing able to form one or more hydrate. Additionally, the compounds ofthe present disclosure, for example, the salts of the compounds, canexist in either hydrated or unhydrated (the anhydrous) form or assolvates with other solvent molecules. Non-limiting examples of hydratesinclude monohydrates, dihydrates, etc. Non-limiting examples of solvatesinclude ethanol solvates, acetone solvates, etc.

“Tautomers” refers to compounds whose structures differ markedly inarrangement of atoms, but which exist in easy and rapid equilibrium. Itis to be understood that obeticholic acid may be depicted as differenttautomers. It should also be understood that when obeticholic acid andsynthetic intermediates of the disclosure have tautomeric forms, alltautomeric forms are intended to be within the scope of the disclosure,and the naming of obeticholic acid does not exclude any tautomer form.obeticholic acid and synthetic intermediates of the disclosure can existin several tautomeric forms, including the keto-enol. For example, inketo-enol tautomerism a simultaneous shift of electrons and a hydrogenatom occurs. Tautomers exist as mixtures of a tautomeric set insolution. In solid form, usually one tautomer predominates. Even thoughone tautomer may be described, the present disclosure includes alltautomers of the present compounds.

It is to be understood accordingly that the isomers arising fromasymmetric carbon atoms (e.g., all enantiomers and diastereomers) areincluded within the scope of the disclosure, unless indicated otherwise.Such isomers can be obtained in substantially pure form by classicalseparation techniques and by stereochemically controlled synthesis.Furthermore, the structures and other compounds and moieties discussedin this application also include all tautomers thereof. Alkenes caninclude either the E- or Z-geometry, where appropriate. Obeticholic acidand synthetic intermediates may exist in stereoisomeric form, andtherefore can be produced as individual stereoisomers or as mixtures.

A “pharmaceutical composition” is a formulation containing obeticholicacid in a form suitable for administration to a subject. In oneembodiment, the pharmaceutical composition is in bulk or in unit dosageform. It is can be advantageous to formulate compositions in dosage unitform for ease of administration and uniformity of dosage. Dosage unitform, as used herein, refers to physically discrete units suited asunitary dosages for the subject to be treated; each unit containing apredetermined quantity of active reagent calculated to produce thedesired therapeutic effect in association with the requiredpharmaceutical carrier. The specification for the dosage unit forms ofthe disclosure are dictated by and directly dependent on the uniquecharacteristics of the active reagent and the particular therapeuticeffect to be achieved, and the limitations inherent in the art ofcompounding such an active agent for the treatment of individuals.

The term “unit dosage form” refers to physically discrete units suitableas unitary dosages for human subjects and other mammals, each unitcontaining a predetermined quantity of active material calculated toproduce the desired therapeutic effect, in association with a suitablepharmaceutical excipient as described above.

The unit dosage form is any of a variety of forms, including, forexample, a capsule, an IV bag, a tablet, a single pump on an aerosolinhaler, or a vial. The quantity obeticholic acid (e.g., a formulationof obeticholic acid, or a pharmaceutically acceptable salt, solvate, oramino acid conjugate thereof) in a unit dose of composition is aneffective amount and is varied according to the particular treatmentinvolved. One skilled in the art will appreciate that it is sometimesnecessary to make routine variations to the dosage, depending on the ageand condition of the patient. The dosage will also depend on the routeof administration. A variety of routes are contemplated, including oral,pulmonary, rectal, parenteral, transdermal, subcutaneous, intravenous,intramuscular, intraperitoneal, inhalational, buccal, sublingual,intrapleural, intrathecal, intranasal, and the like. Dosage forms forthe topical or transdermal administration of a compound of thisdisclosure include powders, sprays, ointments, pastes, creams, lotions,gels, solutions, patches and inhalants. In one embodiment, obeticholicacid is mixed under sterile conditions with a pharmaceuticallyacceptable carrier, and with any preservatives, buffers, or propellantsthat are required.

The term “flash dose” refers to obeticholic acid formulations that arerapidly dispersing dosage forms.

The term “immediate release” is defined as a release of obeticholic acidfrom a dosage form in a relatively brief period of time, generally up toabout 60 minutes. The term “modified release” is defined to includedelayed release, extended release, and pulsed release. The term “pulsedrelease” is defined as a series of releases of drug from a dosage form.The term “sustained release” or “extended release” is defined ascontinuous release of obeticholic acid from a dosage form over aprolonged period.

A “subject” or “patient” includes mammals, e.g., humans, companionanimals (e.g., dogs, cats, birds, and the like), farm animals (e.g.,cows, sheep, pigs, horses, fowl, and the like) and laboratory animals(e.g., rats, mice, guinea pigs, birds, and the like). In one embodiment,the patient is human. In one embodiment, the subject is human child(e.g., between about 30 kg to about 70 kg). In one embodiment, the humanchild has had a Kasai procedure, where the Kasai procedure effectivelygives them a functional bile duct when they are born either without abile duct or a bile duct that is completely blocked at birth.

As used herein, the phrase “pharmaceutically acceptable” refers to thosecompounds, materials, compositions, carriers, and/or dosage forms whichare, within the scope of sound medical judgment, suitable for use incontact with the tissues of human beings and animals without excessivetoxicity, irritation, allergic response, or other problem orcomplication, commensurate with a reasonable benefit/risk ratio.

“Pharmaceutically acceptable excipient” means an excipient that isuseful in preparing a pharmaceutical composition that is generally safe,non-toxic and neither biologically nor otherwise undesirable, andincludes excipient that is acceptable for veterinary use as well ashuman pharmaceutical use. A “pharmaceutically acceptable excipient” asused in the specification and claims includes both one and more than onesuch excipient.

A pharmaceutical composition of the disclosure is formulated to becompatible with its intended route of administration. Examples of routesof administration include parenteral, e.g., intravenous, intradermal,subcutaneous, oral (e.g., inhalation), transdermal (topical), andtransmucosal administration. Solutions or suspensions used forparenteral, intradermal, or subcutaneous application can include thefollowing components: a sterile diluent such as water for injection,saline solution, fixed oils, polyethylene glycols, glycerine, propyleneglycol or other synthetic solvents; antibacterial agents such as benzylalcohol or methyl parabens; antioxidants such as ascorbic acid or sodiumbisulfite; chelating agents such as ethylenediaminetetraacetic acid(EDTA); buffers such as acetates, citrates or phosphates, and agents forthe adjustment of tonicity such as sodium chloride or dextrose. The pHcan be adjusted with acids or bases, such as hydrochloric acid or sodiumhydroxide. The parenteral preparation can be enclosed in ampoules,disposable syringes or multiple dose vials made of glass or plastic.

“Process of the disclosure” refers to a method for preparing obeticholicacid as described herein, wherein the method comprises preparing acrystalline form of obeticholic acid.

A “control” as used herein refers to a baseline level determined on apatient-by-patient basis, an amount or level considered by those skilledin the art as a normal value, or any level or measure of a condition orbiomarker described herein taken from a patient or population ofpatients at any given time for a given condition.

“Fibrosis” refers to a condition involving the development of excessivefibrous connective tissue, e.g., scar tissue, in a tissue or organ. Suchgeneration of scar tissue may occur in response to infection,inflammation, or injury of the organ due to a disease, trauma, chemicaltoxicity, and so on. Fibrosis may develop in a variety of differenttissues and organs, including the liver, kidney, intestine, lung, heart,etc.

As used herein, a “cholestatic condition” refers to any disease orcondition in which bile excretion from the liver is impaired or blocked,which can occur either in the liver or in the bile ducts. Intrahepaticcholestasis and extrahepatic cholestasis are the two types ofcholestatic conditions. Intrahepatic cholestasis (which occurs insidethe liver) is most commonly seen in primary biliary cirrhosis, primarysclerosing cholangitis, sepsis (generalized infection), acute alcoholichepatitis, drug toxicity, total parenteral nutrition (being fedintravenously), malignancy, cystic fibrosis, and pregnancy. Extrahepaticcholestasis (which occurs outside the liver) can be caused by bile ducttumors, strictures, cysts, diverticula, stone formation in the commonbile duct, pancreatitis, pancreatic tumor or pseudocyst, and compressiondue to a mass or tumor in a nearby organ.

Clinical symptoms and signs of a cholestatic condition include: itching(pruritus), fatigue, jaundiced skin or eyes, inability to digest certainfoods, nausea, vomiting, pale stools, dark urine, and right upperquadrant abdominal pain. A patient with a cholestatic condition can bediagnosed and followed clinically based on a set of standard clinicallaboratory tests, including measurement of levels of alkalinephosphatase, γ-glutamyl transpeptidase (GGT), 5′ nucleotidase,bilirubin, bile acids, and cholesterol in a patient's blood serum.Generally, a patient is diagnosed as having a cholestatic condition ifserum levels of all three of the diagnostic markers alkalinephosphatase, GGT, and 5′ nucleotidase, are considered abnormallyelevated. The normal serum level of these markers may vary to somedegree from laboratory to laboratory and from procedure to procedure,depending on the testing protocol. Thus, a physician will be able todetermine, based on the specific laboratory and test procedure, what anabnormally elevated blood level is for each of the markers. For example,a patient suffering from a cholestatic condition generally has greaterthan about 125 IU/L alkaline phosphatase, greater than about 65 IU/LGGT, and greater than about 17 NIL 5′ nucleotidase in the blood. Becauseof the variability in the level of serum markers, a cholestaticcondition may be diagnosed on the basis of abnormal levels of thesethree markers in addition to at least one of the symptoms mentionedabove, such as itching (pruritus).

In one aspect, the disclosure provides a composition comprisingobeticholic acid, or a pharmaceutically acceptable salt, ester, or aminoacid conjugate thereof, wherein obeticholic acid or a pharmaceuticallyacceptable salt, ester, or amino acid conjugate thereof is in the formof particles, and wherein at least 50% of the particles have a diameterof less than 200 μm. The composition of the disclosure possessesadvantageous properties, including improved dissolution profile andsolubility.

In one embodiment, 90% of the particles have a diameter of 400 μm orless, 300 μm or less, 200 μm or less, 100 μm or less, 90 μm or less, 80μm or less, 70 μm or less, 60 μm or less, 50 μm or less, 25 μm or less.In a further embodiment, 90% of the particles have a diameter of 300 μmor less, such as 200 μm or less, 100 μm or less, 90 μm or less, 80 μm orless, 70 μm or less, 60 μm or less, 50 μm or less, 25 μm or less. In afurther embodiment, 90% of the particles have a diameter of 100 μm orless, such as 90 μm or less, 80 μm or less, 70 μm or less, morepreferably 60 μm or less, more preferably 50 μm or less, 25 μm or less.In a further embodiment, 90% of the particles have a diameter of 90 μmor less, such as 80 μm or less, 70 μm or less, 60 μm or less, 50 μm orless, 25 μm or less. In a further embodiment, 90% of the particles havea diameter of 50 μm or less, such as 25 μm or less. In a furtherembodiment, 90% of the particles have a diameter of 25 μm or less.

In one embodiment, 50% of the particles have a diameter of 200 μm orless, such as 150 μm or less, 100 μm or less, 80 μm or less, 60 μm orless, 40 μm or less, 20 μm or less, 15 μm or less, 10 μm or less, 5 μmor less. In a further embodiment, 50% of the particles have a diameterof 100 μm or less, such as 80 μm or less, 60 μm or less, 40 μm or less,20 μm or less, 15 μm or less, more preferably 10 μm or less, 5 μm orless. In a further embodiment, 50% of the particles have a diameter of20 μm or less, such as 15 μm or less, 10 μm or less, 5 μm or less. In afurther embodiment, 50% of the particles have a diameter of 10 μm orless, such as 5 μm or less. In a further embodiment, 50% of theparticles have a diameter of 5 μm or less.

In one embodiment, 10% of the particles have a diameter of 5 μm or less,such as 4 μm or less, 3 μm or less, 2 μm or less, 1 μm or less. In afurther embodiment, 10% of the particles have a diameter of 3 μm orless, 2 μm or less, or 1 μm or less. In a further embodiment, 10% of theparticles have a diameter of 2 μm or less, such as, e.g., 1 μm or less.In a further embodiment, 10% of the particles have a diameter of 1 μm orless.

In one embodiment, 90% of the particles have a diameter of 400 μm orless, 50% of the particles have a diameter of 200 μm or less, and 10% ofthe particles have a diameter of 5 μm or less. In a further embodiment,90% of the particles have a diameter of 300 μm or less, 50% of theparticles have a diameter of 150 μm or less, and 10% of the particleshave a diameter of 5 μm or less. In another embodiment, 90% of theparticles have a diameter of 100 μm or less, 50% of the particles have adiameter of 50 μm or less, and 10% of the particles have a diameter of 5μm or less. In another embodiment, 90% of the particles have a diameterof 100 μm or less, 50% of the particles have a diameter of 20 μm orless, and 10% of the particles have a diameter of 5 μm or less.

In yet another embodiment, 90% of the particles have a diameter of 100μm or less, 50% of the particles have a diameter of 10 μm or less, and10% of the particles have a diameter of 5 μm or less. In yet anotherembodiment, 90% of the particles have a diameter of 90 μm or less, 50%of the particles have a diameter of 10 μm or less, and 10% of theparticles have a diameter of 5 μm or less. In another embodiment, 90% ofthe particles have a diameter of 50 μm or less, 50% of the particleshave a diameter of 10 μm or less, and 10% of the particles have adiameter of 5 μm or less. In a further embodiment, 90% of the particleshave a diameter of 50 μm or less, 50% of the particles have a diameterof 5 μm or less, and 10% of the particles have a diameter of 1 μm orless. In a further embodiment, 90% of the particles have a diameter of25 μm or less, 50% of the particles have a diameter of 5 μm or less, and10% of the particles have a diameter of 1 μm or less.

In one embodiment, 99% of the particles have a diameter of 200 μm orless, such as 1 μm to 100 μm, and 1 μm to 80 μm; 90% of the particleshave a diameter of 200 μm or less, such as 2 μm to 100 μm, and 2 μm to80 μm; and 50% of the particles have a diameter of 200 μm or less, suchas 7 μm to 100 μm, 8 μm to 100 μm, and 9 μm to 80 μm. Furthermorepreferably 90% of the particles have a diameter of 100 μm or less, and50% of the particles have a diameter of 90 μm or less.

In one embodiment, 50% of the particles have a diameter of 100 μm orless, such as 5 μm to 100 μm, and 5 μm to 50 μm; 90% of the particleshave a diameter of 200 μm or less, such as 3 μm to 200 μm, and 3 μm to150 μm; and 99% of the particles have a diameter of 300 μm or less, suchas 1 μm to 300 μm, and 1 μm to 200 μm. In a further embodiment, 90% ofthe particles have a diameter of 150 μm or less, such as 3 μm to 150 μm,and 3 μm to 100 μm; and 99% of the particles have a diameter of 200 μmor less, such as 1 μm to 200 μm, and 1 μm to 150 μm. In a furtherembodiment, 99% of the particles have a diameter of 150 μm or less,preferably 2 μm to 150 μm, and more preferably 2 μm to 100 μm.

In the present disclosure, the “particle size reduction” is carried outfor the purpose of crushing solid particles by the application ofmechanical force such as impact, shearing, or friction thereto to reducethe particle sizes, thereby facilitating the formation of a homogeneousmixed state and improving the dissolution rate and bioavailability ofthe drug owing to the increased surface area (which refers to asspecific surface area, or “SSA”) of the drug. Known particle sizereduction methods include, but are not limited to: high-speed rotatingimpact mills (hammer mills and impact mills), which reduce particle sizeby means of the impact force of a high-speed rotating hammer or pin in achamber; carrier mills (ball mills or vibration mills) which reduceparticle size powder by means of impact force or friction force in arotating cylinder in which the powder and magnetic balls are placed; andfluid energy mills (jet mills), which reduce particle size by jettingcompressed air and raw material particles from a nozzle and collidingthe particles accelerated by the jet of air with swirling particles in achamber. In one embodiment, the particle size of obeticholic acid isreduced using a jet mill. “Micronization,” as defined herein, is areduction of particle size of an active ingredient, i.e., obeticholicacid, to a diameter that is less than about 200 μm, such as less thanabout 100 μm, less than about 50 μm, and less than 25 μm.

In some examples, obeticholic acid has a particle size distribution witha D₅₀ of not more than 100 μm. In specific embodiments, the D₅₀ is notmore than 50 μm, not more than 20 μm, or not more than 10 μm. In otherexamples, the D₉₀ is not more than 200 μm, or not more than 100 μm. Instill other examples, the D₁₀ is not more than 20 μm, not more than 10μm, or not more than 5 μm.

Particle size analysis can be carried out via different methods.Non-limiting examples of the methods include, but are not limited to,sieve technique, wet dispersion method with laser diffraction analysis,dry dispersion method with laser diffraction analysis, or a combinationthereof. Particle size analysis is not limited to the methods describedherein and can be carried out using any method known to one skilled inthe art. In one embodiment, particle size analysis can be performed viaa sieve technique. In another embodiment, particle size analysis can beperformed using a wet dispersion method (e.g., water as the dispersingagent, and analysis by laser diffraction using, e.g., Sympatecequipment). In yet another embodiment, particle size analysis can beperformed using a dry dispersion method and analyzed by laserdiffraction using, e.g., Sympatec equipment.

In one embodiment, particle size distribution (% volume at each particlesize) is measured via a Sympatec laser diffraction analyzer (e.g.,Helos/KF-Magic F71000 with Rodos Dispersing Unit, Vibri sampling unitwith Sniffer rotation, Nilfisk exhaustion, or equivalent). In anotherembodiment, particle size distribution (% volume at each particle size)is measured via a Malvern laser diffraction analyzer.

For example, particles can be measured using the following:

Particle diameter distribution measurement apparatus: HELOS (KF-MagicF71000) & RODOS System (manufactured by Sympatec GmbH);

Measurement range of laser diffraction apparatus: 0.5/0.9 to 175 μm;

Calculation mode of laser diffraction apparatus: Fraunhofer HRLD (v3.2Rel. 2);

Disperser: RODOS, dry dispersion system;

Dispersive pressure: 1.0 bar.

The composition of the present disclosure comprising obeticholic acid ora pharmaceutically acceptable salt, ester, or amino acid conjugatethereof, in the form of particles, offers improved dissolution andsolubility.

Without any intent to be bound by theory, obeticholic acid (OCA)(pK_(a)=4.82) exhibits a pH-solubility profile consistent with that of aweak acid. Solutions of OCA at pH 6.8 to 10 produce clear solutions.However, recovery of OCA steadily diminishes at pH higher than 8.0,indicating basic decomposition of OCA. Despite the solubility observedat pH 6.8 to 10, the particle size distribution of OCA is believed toimpact its dissolution rate.

In one embodiment, in vitro dissolution rates or profiles of the entireactive ingredient of the pharmaceutical composition are measured fromthe entire pharmaceutical composition according to the steps andconditions in Example 3. The dissolution rate can be measured in avariety of buffers, which optionally contains one or more surfactants.Non-limiting examples of buffers include acetate buffer, phosphatebuffers, and alkaline borate buffers, or a combination thereof.Non-limiting examples of surfactants include, polysorbate 80 (Tween80®), potassium laurate, sodium laurate, triethanol ammonium laurate,potassium myristate, sodium myristate, triethanol ammonium myristate,sodium lauryl sulfate, polyoxyethylene alkyl ether sodium sulfate,sodium alkyl β-alanine, sodium sulfosuccinate, acylmethyl taurine,sodium alkylethane suifonate, polyoxyethylene alkyl ether sodiumcarboxylate, trimethyl ammonium chloride, benzalkonium chloride, laurylamine oxide, amide propyl betaine coconut fatty add, amide propylbetaine laurate, amide propyl betaine myristate, sorbitan monolaurate,sorbitan monopalmitate, sorbitan sesquioleate, polyoxyethylene sorbitanmonolaurate, polyethylene glycol monooleate, polyoxyethylene alkylether, polyglycol diester, lauroyl diethanol amide, fatty acidisopropanol amide, maltitol hydroxy fatty acid alkyl ether, alkylatedpolysaccharide, alkyl glucoside, and sucrose fatty acid ester or acombination thereof. In one embodiment, the dissolution rate is measuredin Disodium Hydrogen Phosphate Buffer (Na₂HPO₄). In another embodiment,the dissolution rate is measured in a buffer containing a surfactant(e.g., 0.01-0.1% wt/wt). In one embodiment, the surfactant ispolysorbate 80 (Tween 80®).

In one embodiment, in vitro dissolution rates or profiles are measuredby using a using USP II paddle apparatus in Disodium Hydrogen PhosphateBuffer (Na₂HPO₄) at a temperature of about 37±0.5° C. and paddlesrotation between about 50 rpm to about 100 rpm. In another embodiment,in vitro dissolution rates or profiles are measured by using a using USPII paddle apparatus in Disodium Hydrogen Phosphate Buffer (Na₂HPO₄)containing polysorbate 80 (Tween 80®) (e.g., 0.01-0.1% wt/wt) at atemperature of about 37±0.5° C. and paddles rotation between about 50rpm to about 100 rpm. The entire pharmaceutical composition includes theentire active ingredient and if the pharmaceutical composition containsa capsule shell, carrier, excipient, diluent, disintegrating agent,lubricant, binder or any additional agent described in thePharmaceutical Composition Section below, the measurement is performedwith those components.

In one embodiment, in vitro dissolution is conducted at about 75 rpmusing Disodium Hydrogen Phosphate Buffer (Na₂HPO₄). In anotherembodiment, in vitro dissolution is conducted at 75 rpm using about 900mL of a Disodium Hydrogen Phosphate Buffer (Na₂HPO₄). Solutions arecollected at 15 minutes, 30 minutes, 45 minutes, 60 minutes, and 75minutes after the start of the dissolution. The dissolution rate of thecompound is measured by high-performance liquid chromatography (HPLC)with Corona Charged Aerosol Detection (CAD).

In one embodiment, the concentration for OCA (e.g., in a DisodiumHydrogen Phosphate Buffer, optionally containing a surfactant, such aspolysorbate 80 (Tween 80®)), after dissolution is between about 0.001mg/mL to about 0.01 mg/mL, or between about 0.001 mg/mL to about 0.03mg/mL. Above pH 6.8, the solubility of OCA is well above 0.01 mg/mL.

In one embodiment, the concentration for dissolved 5 mg tablets of OCAis between about 0.001 mg/mL to about 0.02 mg/mL. In another embodiment,the concentration for dissolved 5 mg tablets of OCA is between about0.003 mg/mL to about 0.01 mg/mL. In yet another embodiment, theconcentration for dissolved 5 mg tablets of OCA is between about 0.004mg/mL to about 0.009 mg/mL. In another embodiment, the concentration fordissolved 5 mg tablets of OCA is between about 0.005 mg/mL to about0.008 mg/mL. In yet another embodiment, the concentration for dissolved5 mg tablets of OCA is between about 0.006 mg/mL to about 0.007 mg/mL.In another embodiment, the concentration for dissolved 5 mg tablets ofOCA is about 0.006 mg/mL. In yet another embodiment, the concentrationfor dissolved 5 mg tablets of OCA is about 0.0056 mg/mL.

In one embodiment, the concentration for dissolved 10 mg tablets of OCAis between about 0.001 mg/mL to about 0.03 mg/mL. In another embodiment,the concentration for dissolved 10 mg tablets of OCA is between about0.005 mg/mL to about 0.025 mg/mL. In yet another embodiment, theconcentration for dissolved 10 mg tablets of OCA is between about 0.008mg/mL to about 0.02 mg/mL. In another embodiment, the concentration fordissolved 10 mg tablets of OCA is between about 0.009 mg/mL to about0.015 mg/mL. In yet another embodiment, the concentration for dissolved10 mg tablets of OCA is about 0.011 mg/mL. In another embodiment, theconcentration for dissolved 10 mg tablets of OCA is about 0.010 mg/mL.

In one embodiment, the concentration for dissolved 25 mg tablets of OCAis between about 0.001 mg/mL to about 0.05 mg/mL. In another embodiment,the concentration for dissolved 25 mg tablets of OCA is between about0.01 mg/mL to about 0.08 mg/mL. In yet another embodiment, theconcentration for dissolved 25 mg tablets of OCA is between about 0.02mg/mL to about 0.06 mg/mL. In another embodiment, the concentration fordissolved 25 mg tablets of OCA is between about 0.025 mg/mL to about0.04 mg/mL. In yet another embodiment, the concentration for dissolved25 mg tablets of OCA is about 0.026 mg/mL to about 0.03 mg/mL. Inanother embodiment, the concentration for dissolved 25 mg tablets of OCAis about 0.028 mg/mL.

In one embodiment, the composition of the present disclosure comprisingobeticholic acid or a pharmaceutically acceptable salt, ester, or aminoacid conjugate thereof, in the form of particles, provides improveddissolution of obeticholic acid or a pharmaceutically acceptable salt,ester, or amino acid conjugate thereof. For example, obeticholic acid ora pharmaceutically acceptable salt, ester, or amino acid conjugatethereof in the particle composition of the present disclosure dissolves(e.g., in a Disodium Hydrogen Phosphate Buffer) at a rate that is atleast 2%, 3%, 4%, 5%, 6%, 7%, 8%, 9%, 10%, 15%, 20%, 30%, 40%, 50%, 80%,or 100% faster than the dissolution rate when obeticholic acid or apharmaceutically acceptable salt, ester, or amino acid conjugate thereofis not present in the particle composition of the present disclosure.

For example, about 55% to about 95% of obeticholic acid or apharmaceutically acceptable salt, ester, or amino acid conjugate thereofin the particle composition of the present disclosure is dissolvedwithin about 15 minutes, or about 65% to about 95% is dissolved withinabout 30 minutes, or about 80% to about 95% is dissolved within about 45minutes, or about 87% to about 97% is dissolved within about 60 minutes,or about 87% to about 99% is dissolved within about 75 minutes. Forexample, about 60% to about 84% of obeticholic acid or apharmaceutically acceptable salt, ester, or amino acid conjugate thereofin the particle composition of the present disclosure is dissolvedwithin about 15 minutes, or about 75% to about 91% is dissolved withinabout 30 minutes, or about 85% to about 93% is dissolved within about 45minutes, or about 90% to about 96% is dissolved within about 60 minutes,or about 90% to about 97% is dissolved within about 75 minutes. Forexample, about 62% to about 83% of obeticholic acid or apharmaceutically acceptable salt, ester, or amino acid conjugate thereofin the particle composition of the present disclosure is dissolvedwithin about 15 minutes, or about 80% to about 90% is dissolved withinabout 30 minutes, or about 87% to about 94% is dissolved within about 45minutes, or about 92% to about 96% is dissolved within about 60 minutes,or about 91% to about 97% is dissolved within about 75 minutes. Forexample, about 60% to about 84% obeticholic acid or a pharmaceuticallyacceptable salt, ester, or amino acid conjugate thereof in the particlecomposition of the present disclosure is dissolved within about 15minutes, or about 70% to about 90% is dissolved within about 30 minutes,or about 85% to about 92% is dissolved within about 45 minutes, or about89% to about 96% is dissolved within about 60 minutes, or about 90% toabout 96% is dissolved within about 75 minutes. For example, at leastabout 60% obeticholic acid or a pharmaceutically acceptable salt, ester,or amino acid conjugate thereof in the particle composition of thepresent disclosure is dissolved within about 15 minutes, or at leastabout 90% is dissolved within about 60 minutes. For example, obeticholicacid or a pharmaceutically acceptable salt, ester, or amino acidconjugate thereof in the particle composition of the present disclosurehas an in vitro dissolution profile of about 51% dissolved within about15 minutes, or about 66% dissolved within about 30 minutes, or about 79%dissolved within about 45 minutes, or about 85% dissolved within about60 minutes.

In one embodiment, the composition of the present disclosure comprisingobeticholic acid or a pharmaceutically acceptable salt, ester, or aminoacid conjugate thereof, in the form of particles, provides improvedsolubility of obeticholic acid or a pharmaceutically acceptable salt,ester, or amino acid conjugate thereof. For example, obeticholic acid ora pharmaceutically acceptable salt, ester, or amino acid conjugatethereof in the particle composition of the present disclosure has asolubility (e.g., in a Disodium Hydrogen Phosphate Buffer) that is atleast 2%, 3%, 4%, 5%, 6%, 7%, 8%, 9%, 10%, 15%, 20%, 30%, 40%, 50%, 80%,or 100% higher than the solubility when obeticholic acid or apharmaceutically acceptable salt, ester, or amino acid conjugate thereofis not present in the particle composition of the present disclosure.For example, obeticholic acid or a pharmaceutically acceptable salt,ester, or amino acid conjugate thereof in the particle composition ofthe present disclosure has a solubility (e.g., in a Disodium HydrogenPhosphate Buffer) that is at least 2%, 3%, 4%, 5%, 6%, 7%, 8%, 9%, 10%,15%, or 20% higher than the solubility when obeticholic acid or apharmaceutically acceptable salt, ester, or amino acid conjugate thereofis not present in the particle composition of the present disclosure ata pH (e.g., pH 6.8) at which obeticholic acid has the highest solubility(e.g., freely soluble) when not present in the particle composition ofthe present disclosure.

In one embodiment, obeticholic acid, or a pharmaceutically acceptablesalt, ester, or amino acid conjugate thereof, and/or particles ofobeticholic acid, or a pharmaceutically acceptable salt, ester, or aminoacid conjugate thereof, has a solubility of about 0.001 to about 0.600mg/mL. In another embodiment, obeticholic acid, or a pharmaceuticallyacceptable salt, ester, or amino acid conjugate thereof, and/orparticles of obeticholic acid, or a pharmaceutically acceptable salt,ester, or amino acid conjugate thereof, has a solubility of about 0.02to about 0.500 mg/mL. In yet another embodiment, obeticholic acid, or apharmaceutically acceptable salt, ester, or amino acid conjugatethereof, and/or particles of obeticholic acid, or a pharmaceuticallyacceptable salt, ester, or amino acid conjugate thereof, has asolubility of about 0.03 to about 0.48 mg/mL. In another embodiment,obeticholic acid, or a pharmaceutically acceptable salt, ester, or aminoacid conjugate thereof, and/or particles of obeticholic acid, or apharmaceutically acceptable salt, ester, or amino acid conjugatethereof, has a solubility of about 0.05 to about 0.46 mg/mL. In yetanother embodiment, obeticholic acid, or a pharmaceutically acceptablesalt, ester, or amino acid conjugate thereof, and/or particles ofobeticholic acid, or a pharmaceutically acceptable salt, ester, or aminoacid conjugate thereof, has a solubility of about 0.1 to about 0.5mg/mL. In another embodiment, obeticholic acid, or a pharmaceuticallyacceptable salt, ester, or amino acid conjugate thereof, and/orparticles of obeticholic acid, or a pharmaceutically acceptable salt,ester, or amino acid conjugate thereof, has a solubility of about 0.2 toabout 0.6 mg/mL.

The disclosure also comprehends isotopically-labeled obeticholic acid,or pharmaceutically acceptable salts, solvate, or amino acid conjugatesthereof, which are identical to those recited in formulae of thedisclosure and following, but for the fact that one or more atoms arereplaced by an atom having an atomic mass or mass number different fromthe atomic mass or mass number most commonly found in nature. Examplesof isotopes that can be incorporated into obeticholic acid, orpharmaceutically acceptable salts, solvate, or amino acid conjugatesthereof include isotopes of hydrogen, carbon, nitrogen, fluorine, suchas ³H, ¹¹C, ¹⁴C and ¹⁸F.

Obeticholic acid, or pharmaceutically acceptable salts, solvates, oramino acid conjugates thereof that contain the aforementioned isotopesand/or other isotopes of other atoms are within the scope of the presentdisclosure. Isotopically-labeled obeticholic acid, or pharmaceuticallyacceptable salts, solvates, or amino acid conjugates thereof, forexample those into which radioactive isotopes such as ³H, ¹⁴C areincorporated, are useful in drug and/or substrate tissue distributionassays. Tritiated, i.e., ³H, and carbon-14, i.e., ¹⁴C, isotopes areparticularly preferred for their ease of preparation and detectability.Further, substitution with heavier isotopes such as deuterium, i.e., ²H,can afford certain therapeutic advantages resulting from greatermetabolic stability, for example increased in vivo half-life or reduceddosage requirements and, hence, may be preferred in some circumstances,isotopically labeled obeticholic acid, or pharmaceutically acceptablesalts, solvates, or amino acid conjugates thereof can generally beprepared by carrying out the procedures disclosed in the Schemes and/orin the Examples of the disclosure, by substituting a readily availableisotopically labeled reagent for a non-isotopically labeled reagent. Inone embodiment, obeticholic acid, or pharmaceutically acceptable salts,solvates, or amino acid conjugates thereof are not isotopically labeled.In one embodiment, deuterated obeticholic acid is useful forbioanalytical assays. In another embodiment, obeticholic acid, orpharmaceutically acceptable salts, solvates, or amino acid conjugatesthereof are radiolabeled.

In another aspect, the disclosure provides a composition comprisingobeticholic acid, or a pharmaceutically acceptable salt, ester, or aminoacid conjugate thereof, and a pharmaceutically acceptable excipienthaving a low alcohol (e.g., an impurity having at least one primary OHgroup, such as ethanol or methanol) content. In one embodiment, thealcohol is a primary alcohol. As defined herein “primary alcohol” is analcohol which has a hydroxy group connected to a primary carbon atom.The composition of the disclosure possesses advantageous properties,including improved stability of obeticholic acid in the composition.

The excipient can be any excipient present in the composition comprisingobeticholic acid, or a pharmaceutically acceptable salt, ester, or aminoacid conjugate thereof. Examples of excipients include, but are notlimited to, calcium phosphate, microcrystalline cellulose, sodium starchglycolate and magnesium stearate, or a combination thereof. In oneembodiment, the excipient can be any excipient known in the art. Inanother embodiment, the excipient is selected from calcium phosphate,microcrystalline cellulose, sodium starch glycolate and magnesiumstearate. In yet another embodiment, the excipient is selected frommicrocrystalline cellulose, sodium starch glycolate and magnesiumstearate. In another embodiment, the excipient is the excipient ismagnesium stearate. In yet another embodiment, the excipient ismicrocrystalline cellulose. In a further embodiment, the excipient issodium starch glycolate.

In one embodiment, the excipient has an impurity having a primaryalcohol group. In another embodiment, the impurity in the excipient isethanol, methanol, polyvinyl alcohol, polyethylene glycol, or asubstance having at least one primary OH moiety.

In one embodiment, the total alcohol (e.g., the impurity having at leastone primary OH group) content in the excipient is less than 6%, 5%,4.5%, 4%, 3.5%, 3%, 2.5%, 2%, 1.5%, 1%, or 0.5% (wt/wt). In oneembodiment, the alcohol is a substance having at least one primary OHmoiety. In one embodiment, the alcohol is ethanol, methanol, polyvinylalcohol, polyethylene glycol, or a combination thereof. In oneembodiment, the total content of ethanol, methanol, polyvinyl alcohol,polyethylene glycol, or a combination thereof in the excipient is lessthan 6%, 5%, 4.5%, 4%, 3.5%, 3%, 2.5%, 2%, 1.5%, 1%, or 0.5% (wt/wt).

In one embodiment, the alcohol is ethanol. In one embodiment, the totalethanol content in the excipient is less than 6%, 5%, 4.5%, 4%, 3.5%,3%, 2.5%, 2%, 1.5%, 1%, or 0.5% (wt/wt). In another embodiment, theexcipient is sodium starch glycolate. In one embodiment, the sodiumstarch glycolate comprises less than 6%, 5%, 4.5%, 4%, 3.5%, 3%, 2.5%,2%, 1.5%, 1%, or 0.5% (wt/wt) ethanol.

In one embodiment, the alcohol is methanol. In one embodiment, the totalmethanol content in the excipient is less than 6%, 5%, 4.5%, 4%, 3.5%,3%, 2.5%, 2%, 1.5%, 1%, or 0.5% (wt/wt).

In another embodiment, the alcohol is a substance having at least oneprimary OH moiety. In one embodiment, the total content of the substancehaving at least one primary OH moiety in the excipient is less than 6%,5%, 4.5%, 4%, 3.5%, 3%, 2.5%, 2%, 1.5%, 1%, or 0.5% (wt/wt).

In one embodiment, the alcohol is polyvinyl alcohol. In one embodiment,the total polyvinyl alcohol content in the excipient is less than 6%,5%, 4.5%, 4%, 3.5%, 3%, 2.5%, 2%, 1.5%, 1%, or 0.5% (wt/wt). In oneembodiment, the excipient is sodium starch glycolate. In one embodiment,the sodium starch glycolate comprises less than 6%, 5%, 4.5%, 4%, 3.5%,3%, 2.5%, 2%, 1.5%, 1%, or 0.5% (wt/wt) polyvinyl alcohol.

In one embodiment, the alcohol is polyethylene glycol. In oneembodiment, the total polyethylene glycol content in the excipient isless than 6%, 5%, 4.5%, 4%, 3.5%, 3%, 2.5%, 2%, 1.5%, 1%, or 0.5%(wt/wt). In one embodiment, the excipient is sodium starch glycolate. Inone embodiment, the sodium starch glycolate comprises less than 6%, 5%,4.5%, 4%, 3.5%, 3%, 2.5%, 2%, 1.5%, 1%, or 0.5% (wt/wt) polyethyleneglycol.

The composition comprising obeticholic acid, or a pharmaceuticallyacceptable salt, ester, or amino acid conjugate thereof, and apharmaceutically acceptable excipient having low alcohol content offersadvantageous stability of obeticholic acid upon storage under variousconditions.

In one embodiment, the composition comprising obeticholic acid, or apharmaceutically acceptable salt, ester, or amino acid conjugatethereof, and a pharmaceutically acceptable excipient having a lowprimary alcohol content comprises a decreased amount of impurities, ascompared to an obeticholic acid composition comprising an excipienthaving a high alcohol (e.g., greater than or equal to 6% (wt/wt)content).

In one embodiment, the impurity is an ester of obeticholic acid. In oneembodiment, the amount of the ester of obeticholic acid is decreased byat least 10%, 20%, 30%, 40%, 50%, 60%, 70%, 80%, 90%, 95%, or 99%. Inone embodiment, the amount of the ester of obeticholic acid is decreasedby at least 50%, 60%, 70%, 80%, 90%, 95%, or 99%.

In one embodiment, the impurity is an ethyl ester of obeticholic acid.In one embodiment, the amount of the ethyl ester of obeticholic acid isdecreased by at least 10%, 20%, 30%, 40%, 50%, 60%, 70%, 80%, 90%, 95%,or 99%. In one embodiment, the amount of the ethyl ester of obeticholicacid is decreased by at least 50%, 60%, 70%, 80%, 90%, 95%, or 99%. Inanother embodiment, the amount of the ethyl ester of obeticholic acid isless than 0.5%, 0.4%, 0.3%, 0.2%, 0.1%, 0.09%, 0.08%, 0.07%, 0.06%,0.05%, 0.04%, 0.03%, 0.02%, or 0.01% (wt/wt). In a further embodiment,the amount of the ethyl ester of obeticholic acid is less than 0.5%,0.4%, 0.3%, 0.2%, 0.1%, 0.09%, 0.08%, 0.07%, 0.06%, 0.05%, 0.04%, 0.03%,0.02%, or 0.01% (wt/wt) at the storage condition of 40° C., 75% RH for 4weeks. In a further embodiment, the amount of the ethyl ester ofobeticholic acid is less than 0.2%, 0.1%, 0.09%, 0.08%, 0.07%, 0.06%,0.05%, 0.04%, 0.03%, 0.02%, or 0.01% (wt/wt) at the storage condition of40° C., 75% RH for 4 weeks.

In one embodiment, the impurity is a methyl ester of obeticholic acid.In one embodiment, the amount of the methyl ester of obeticholic acid isdecreased by at least 10%, 20%, 30%, 40%, 50%, 60%, 70%, 80%, 90%, 95%,or 99%. In one embodiment, the amount of the methyl ester of obeticholicacid is decreased by at least 50%, 60%, 70%, 80%, 90%, 95%, or 99%. Inanother embodiment, the amount of the methyl ester of obeticholic acidis less than 0.5%, 0.4%, 0.3%, 0.2%, 0.1%, 0.09%, 0.08%, 0.07%, 0.06%,0.05%, 0.04%, 0.03%, 0.02%, or 0.01% (wt/wt).

An analysis of the impurities in an obeticholic acid composition (e.g.,the obeticholic acid composition of the present disclosure) can beconducted with methods known to one skilled in the art, for example,with LC/HRMS using LTQ-Orbitrap. The identities of various impuritiescan be confirmed through various techniques available in the art. Forexample, to determine whether an ethyl ester of obeticholic acid is animpurity, obeticholic acid can be dissolved in ethanol, and treated withconcentrated acid and heated to synthesize the ethyl ester. Theretention time and mass spectrometry of the impurity can be comparedwith those of the synthesized ethyl ester of obeticholic acid. Theexcipients were analyzed for ethanol content and excipients containinghigher ethanol content were substituted with a low ethanol contentexcipient.

The composition comprising obeticholic acid, or a pharmaceuticallyacceptable salt, ester, or amino acid conjugate thereof, in the form ofparticles, or the composition comprising obeticholic acid, or apharmaceutically acceptable salt, ester, or amino acid conjugatethereof, and a pharmaceutically acceptable excipient having a lowalcohol content, as disclosed herein, can be incorporated into apharmaceutical composition suitable for administration (e.g., oraladministration).

Thus, in another aspect, the present disclosure provides apharmaceutical composition, comprising a therapeutically effectiveamount of obeticholic acid, or a pharmaceutically acceptable salt,ester, or amino acid conjugate thereof, and a pharmaceuticallyacceptable excipient having a low alcohol content. In one embodiment,the pharmaceutical composition has a low alcohol content as describedherein. In another embodiment, the pharmaceutical composition comprisessodium starch glycolate comprising less than 5% alcohol (e.g., ethanol).

In another embodiment, the pharmaceutical composition comprises atherapeutically effective amount of obeticholic acid, or apharmaceutically acceptable salt, ester, or amino acid conjugatethereof, and a pharmaceutically acceptable excipient having a lowalcohol content, wherein obeticholic acid is in the form of particles.In one embodiment, the particles have a size distribution as describedherein.

In one embodiment, the pharmaceutical composition further comprises oneor more pharmaceutical excipients. The excipient can be one or moreselected from the group consisting of diluents, sweeteners, viscosityenhancing agents, dispersing agents, preservatives, flavoring agents andthe like. One excipient can perform more than one function. In oneembodiment, the one or more pharmaceutical excipients include alubricant and/or a diluent.

Non-limiting examples of sweeteners include natural sweeteners such assugars, e.g., fructose, glucose, sucrose, sugar alcohols such asmannitol, sorbitol or mixtures thereof and artificial sweeteners such assodium saccharine, sodium cyclamate and aspartame. In one embodiment,the sweetener can be any sweetener known in the art. In anotherembodiment, the sweetener is selected from fructose, glucose, sucrose,mannitol, and sorbitol, or a combination thereof.

Dispersing agents include, but are not limited to, colloidal silicondioxide and surfactants, wherein the surfactant is used alone or as anadmixture with one or more surfactant. In one embodiment, the dispersingagent can be any dispersing agent known in the art. Combinations ofcolloidal silicon dioxide with one or more surfactants can also be used.

In one embodiment, the lubricant can be any lubricant known in the art.Non-limiting examples of lubricants include magnesium stearate, calciumstearate, stearic acid, glyceryl behenate, hydrogenated vegetable oil,and glycerine fumarate, and/or a combination thereof. In anotherembodiment, the lubricant is selected from magnesium stearate, calciumstearate, stearic acid, glyceryl behenate, hydrogenated vegetable oil,and glycerine fumarate. In another embodiment, the lubricant is calciumstearate. In yet another embodiment, the lubricant is stearic acid. Infurther embodiment, the lubricant is magnesium stearate.

In one embodiment, the diluent can be any diluent known in the art.Non-limiting examples of diluents include starch, pregelatinized starch,microcrystalline cellulose, calcium carbonate, dibasic calciumphosphate, tribasic calcium phosphate, calcium phosphate, lactose,dextrose, fructose, lactitol, lactose, magnesium carbonate, magnesiumoxide, maltitol, maltodextrin, maltose, simethicone, sodium chloride,talc, xylitol, sorbitol, mannitol, and sucrose, and/or a combinationthereof. In another embodiment, the diluent is selected from starch,pregelatinized starch, microcrystalline cellulose, calcium phosphate,lactose, sorbitol, mannitol, and sucrose. In another embodiment, thediluent is calcium phosphate. In yet another embodiment, the diluent ismannitol. In further embodiment, the diluent is microcrystallinecellulose.

In one embodiment, the pharmaceutical composition may further comprise acoating agent such as sugar-based coating agents, water-soluble filmcoating agents, enteric coating agents and delayed release coatingagents or a coating composition comprising any combination thereof. Inanother embodiment, the coating agent can be any coating agent known inthe art. Examples of coating agents include, but are not limited to,saccharose used alone or together with any of the agents such as talc,calcium carbonate, calcium phosphate, calcium sulphate, gelatine, gumarabic, polyvinylpyrrolidone and pullulan or any combination thereof;cellulose derivatives such as hydroxypropyl cellulose, hydroxypropylmethyl cellulose, hydroxyethyl cellulose, methyl hydroxyethyl celluloseand sodium carboxymethyl cellulose; synthetic polymers such as polyvinylacetal diethyl amino acetate, aminoalkyl methacrylate copolymers andpolyvinylpyrrolidone; polysaccharides such as pullulan; hydroxypropylmethyl cellulose phthalate; hydroxypropyl methyl cellulose acetatesuccinate; carboxymethyl ethyl cellulose; cellulose acetate phthalate;acrylic acid derivatives such as methacrylic acid copolymer L,methacrylic acid copolymer LD and methacrylic acid copolymer S; naturalsubstances such as shellac; titanium dioxide; polyvinyl alcohol (e.g.,Opadry®); polyethylene glycol; talc; lecithin; and/or combinationsthereof. In one embodiment, the coating agent is selected fromhydroxypropyl cellulose, hydroxypropyl methyl cellulose, hydroxyethylcellulose, methyl hydroxyethyl cellulose, sodium carboxymethylcellulose, polyvinyl acetal diethyl amino acetate, polyvinyl alcohol,polyethylene glycol, and lecithin, or a combination thereof. In anotherembodiment, the coating agent is Opadry® II (e.g., Opadry® II green,white, yellow, etc.).

In one embodiment, the pharmaceutical composition comprising obeticholicacid, or a pharmaceutically acceptable salt, ester, or amino acidconjugate thereof, in the form of particles, at about 1% to about 6% byweight, sodium starch glycolate at about 2% to about 8% by weight havinga low alcohol content, a lubricant (e.g., magnesium stearate) at about0.1% to about 2.0% by weight, and a diluent (e.g., microcrystallinecellulose) at about 85% to about 95% by weight. In one embodiment, thesodium starch glycolate comprises less than 6% (wt/wt) ethanol.

In one embodiment, the pharmaceutically composition is in solid particleform. Any inert excipient that is commonly used as a carrier or diluentmay be used in the pharmaceutical composition of the present disclosure,such as for example, a gum, a starch, a sugar, a cellulosic material, aglycolate, an acrylate, or mixtures thereof. In one embodiment, thefiller/diluent is microcrystalline cellulose. The pharmaceuticalcomposition may further comprise a disintegrating agent (e.g., sodiumstarch glycolate) and/or a lubricant (e.g., magnesium stearate). Also,the pharmaceutical composition may comprise one or more additivesselected from a buffer, a surfactant, a solubilizing agent, aplasticizer, an emulsifier, a stabilizing agent, a viscosity increasingagent, a sweetener, a film forming agent, or any combination thereof.Furthermore, the pharmaceutical composition of the present disclosuremay be in the form of controlled release of immediate releaseformulations.

The percentage of the active ingredient (i.e., obeticholic acid, or apharmaceutically acceptable salt, ester, or amino acid conjugatethereof) and various excipients in the pharmaceutical composition of thepresent disclosure may vary. For example, the composition may comprisebetween about 0.1 and about 99%, between about 1-50%, between about1-25%, or about 1-6% by weight of active ingredient. Furthermore, thecomposition may comprise between about 20-99%, between about 45-97%,between about 65-96%, or between about 85-95% by weight microcrystallinecellulose as a filler or diluent. Furthermore, the composition maycomprise between about 1-30%, between about 1-20%, or between about 2-8%by weight sodium starch glycolate as a disintegrant. Furthermore, thecomposition may comprise between about 0.1-5% or about 0.5-2.0% byweight magnesium stearate as a lubricant.

In one embodiment, the pharmaceutical composition of the presentdisclosure is about 0.1% to about 10% by weight of active ingredient(i.e., obeticholic acid, or a pharmaceutically acceptable salt, ester,or amino acid conjugate thereof), about 0.1% to about 20% by weight ofsodium starch glycolate, about 0.01% to about 8.0% by weight ofmagnesium stearate, and about 65% to about 99% by weight ofmicrocrystalline cellulose. In another embodiment, the pharmaceuticalcomposition of the present disclosure is about 0.5% to about 8% byweight of active ingredient, about 1% to about 10% by weight of sodiumstarch glycolate, about 0.05% to about 4.0% by weight of magnesiumstearate, and about 75% to about 97% by weight of microcrystallinecellulose. In yet another embodiment, the pharmaceutical composition ofthe present disclosure is about 1% to about 6% by weight of activeingredient, about 2% to about 8% by weight of sodium starch glycolate,about 0.1% to about 2.0% by weight of magnesium stearate, and about 85%to about 95% by weight of microcrystalline cellulose. In one embodiment,obeticholic acid, or a pharmaceutically acceptable salt, ester, or aminoacid conjugate thereof, in the pharmaceutical composition is in the formof particles, as described herein.

In another aspect, the present disclosure provides a pharmaceuticalcomposition, comprising a therapeutically effective amount ofobeticholic acid, or a pharmaceutically acceptable salt, ester, or aminoacid conjugate thereof, in the form of particles, and a pharmaceuticallyacceptable excipient having a low alcohol content. In one embodiment,the obeticholic acid particle composition is an obeticholic acidparticle composition described herein. In one embodiment, thepharmaceutical composition has a low alcohol content as describedherein. In one embodiment, the pharmaceutical composition comprisessodium starch glycolate comprising less than 6% alcohol (e.g., ethanol).

In another aspect, the present disclosure provides a method forpreparing a pharmaceutical composition containing a therapeuticallyeffective amount of obeticholic acid, or a pharmaceutically acceptablesalt, ester, or amino acid conjugate thereof, in the form of particles,comprising i) micronizing obeticholic acid acceptable salt, ester, oramino acid conjugate thereof until at least 90% of the particles have adiameter of less than 100 μm, such as less than 90 μm, less than 50 μm,less than 25 μm, less than 20 μm, less than 15 μm, less than 10 μm, lessthan 5 μm, or less than 1 μm, and ii) combining the micronizedobeticholic acid particles with at least one pharmaceutically acceptableexcipient. In one embodiment, the micronizing is carried out using ajet-mill.

In another aspect, the present disclosure provides a method forpreparing a pharmaceutical composition containing a therapeuticallyeffective amount of obeticholic acid, or a pharmaceutically acceptablesalt, ester, or amino acid conjugate thereof, in the form of particles,comprising i) micronizing obeticholic acid acceptable salt, ester, oramino acid conjugate thereof until at least 50% of the particles have adiameter of less than 10 μm, i.e., less than 5 μm, and ii) combining themicronized obeticholic acid particles with at least one pharmaceuticallyacceptable excipient. In one embodiment, the micronizing is carried outusing a jet-mill.

In another aspect, the present disclosure provides a method forpreparing a pharmaceutical composition containing a therapeuticallyeffective amount of obeticholic acid, or a pharmaceutically acceptablesalt, ester, or amino acid conjugate thereof, in the form of particles,comprising i) micronizing obeticholic acid acceptable salt, ester, oramino acid conjugate thereof until at least 10% of the particles have adiameter of less than 5 μm, i.e., less than 1 μm, and ii) combining themicronized obeticholic acid particles with at least one pharmaceuticallyacceptable excipient. In one embodiment, the micronizing is carried outusing a jet-mill.

In another aspect, the present disclosure provides a method forpreparing a pharmaceutical composition containing a therapeuticallyeffective amount of obeticholic acid, or a pharmaceutically acceptablesalt, ester, or amino acid conjugate thereof, in the form of particles,comprising i) micronizing obeticholic acid acceptable salt, ester, oramino acid conjugate thereof until at least 90% of the particles have adiameter of less than 100 μm, preferably less than 90 μm, less than 50μm, less than 25 μm, less than 20 μm, less than 15 μm, less than 10 μm,less than 5 μm, less than 1 μm; at least 50% of the particles have adiameter of less than 10 μm, less than 5 μm, less than 1 μm; and atleast 10% of the particles have a diameter of less than 5 μm, or lessthan 1 μm, and ii) combining the micronized obeticholic acid particleswith at least one pharmaceutically acceptable excipient. In oneembodiment, the micronizing is carried out using a jet-mill.

In another aspect, the present disclosure provides a method forpreparing a pharmaceutical composition containing a therapeuticallyeffective amount of obeticholic acid, or a pharmaceutically acceptablesalt, ester, or amino acid conjugate thereof, in the form of particles,comprising i) micronizing obeticholic acid acceptable salt, ester, oramino acid conjugate thereof until at least 90% of the particles have adiameter of less than 100 μm, at least 50% of the particles have adiameter of less than 10 μm, and at least 10% of the particles have adiameter of less than 5 μm, and ii) combining the micronized obeticholicacid particles with at least one pharmaceutically acceptable excipient.In one embodiment, the micronizing is carried out using a jet-mill.

In another aspect, the present disclosure provides a method forpreparing a pharmaceutical composition containing a therapeuticallyeffective amount of obeticholic acid, or a pharmaceutically acceptablesalt, ester, or amino acid conjugate thereof, in the form of particles,comprising i) micronizing obeticholic acid acceptable salt, ester, oramino acid conjugate thereof until at least 90% of the particles have adiameter of less than 25 μm, at least 50% of the particles have adiameter of less than 5 μm, and at least 10% of the particles have adiameter of less than 1 μm, and ii) combining the micronized obeticholicacid particles with at least one pharmaceutically acceptable excipient.In one embodiment, the micronizing is carried out using a jet-mill.

In another aspect the present disclosure provides a method for treatingor preventing a disease or condition, comprising administering aneffective amount of an obeticholic acid composition of the presentdisclosure to a patient in need thereof.

In one aspect, the present disclosure provides a method for treating adisease or condition by administering an effective amount of anobeticholic acid composition described herein to a patient in needthereof. In certain embodiments herein the effective amount refers to atitrated dosage administered during a titration period as set forthherein. In other embodiments, the effective amount refers to an adjustedor re-adjusted dosage administered after a titration period as set forthherein.

It is to be understood that the methods described herein refer generallyto the obeticholic acid compositions set forth herein. The methodsdescribed herein can include any specific formulation provided herein,for example, that provided in Example 11. In one embodiment, theobeticholic acid composition useful in the methods of treating describedherein is a composition provided in Example 11. In another embodiment,the obeticholic acid composition useful in the methods of treatingdescribed herein is a composition that includes microcrystallinecellulose, sodium starch glycolate, and magnesium stearate asexcipients. Such a composition can be provided in a dosage form setforth herein, e.g., an oral dosage form such as a tablet or coatedtablet. Thus, in certain instances, the obeticholic acid compositionuseful in the methods is a tablet or coated tablet for oraladministration. In one embodiment, the oral dosage form of theobeticholic acid composition includes a film coating that includes oneor more excipients selected from polyvinyl alcohol (part hydrolyzed),titanium dioxide, macrogol (polyethylene glycol 3350), talc, and ironoxide.

In one embodiment, the disease or condition is an FXR mediated diseaseor condition. Examples of the FXR mediated diseases or conditionsinclude, but not limited to, liver diseases such as a cholestatic liverdisease such as primary biliary cirrhosis (PBC) also known as primarybiliary cholangitis (PBC), primary sclerosing cholangitis (PSC), chronicliver disease, nonalcoholic fatty liver disease (NAFLD), nonalcoholicsteatohepatitis (NASH), hepatitis C infection, alcoholic liver disease,liver damage due to progressive fibrosis, and liver fibrosis. Examplesof FXR mediated diseases also include portal hypertension, bile aciddiarrhea, hyperlipidemia, high LDL-cholesterol, high HDL-cholesterol,high triglycerides, and cardiovascular disease.

In another aspect, the present disclosure provides methods of treatingor preventing a disease or condition described herein by administeringan obeticholic acid composition described herein (e.g., obeticholic acidor a pharmaceutically acceptable salt, ester, or amino acid conjugatethereof, where the obeticholic acid or a pharmaceutically acceptablesalt, ester, or amino acid conjugate thereof is in the form ofparticles, and wherein at least 50% of the particles have a diameter of200 μm or less).

In still another aspect the present disclosure provides a method oftreating primary biliary cirrhosis (PBC) by administering an obeticholicacid composition described herein (e.g., obeticholic acid or apharmaceutically acceptable salt, ester, or amino acid conjugatethereof, where the obeticholic acid or a pharmaceutically acceptablesalt, ester, or amino acid conjugate thereof is in the form ofparticles, and wherein at least 50% of the particles have a diameter of200 μm or less), optionally in a titration period. In some examples, themethod comprise administering a starting dose in a titration period. Thestarting dose, adjusted dose, and titration period are as describedbelow.

The PBC can be advanced stage PBC. “Advanced stage PBC” refers to PBCcharacterized by one or more of the following: Baseline totalbilirubin>upper liming of normal (ULN); Baseline total ALP>5×ULN;Baseline transient elastography (TE)>10.7 kPa; Cirrhosis based on aninitial or baseline biopsy result or patient having an Ishak score 6(cirrhosis) or Ludwig/Scheuer PBC Stage 4; or Medical history ofascites, hepatic cirrhosis, jaundice, portal hypertension, portalhypertensive gastropathy or varices esophageal.

Further provided herein are methods of treating primary sclerosingcholangitis (PSC), chronic liver disease, nonalcoholic fatty liverdisease (NAFLD), nonalcoholic steatohepatitis (NASH), hepatitis Cinfection, alcoholic liver disease, liver damage due to progressivefibrosis, or liver fibrosis in a patient in need thereof byadministering an effective amount of an obeticholic acid compositiondescribed above. In another embodiment, the method is a method oftreating NAFLD by administering an effective amount of an obeticholicacid composition described above. In still another embodiment, themethod is a method of treating PSC by administering an effective amountof an obeticholic acid composition described above. In yet anotherembodiment, the method is a method of treating fibrosis (e.g.,progressive or liver fibrosis) by administering an effective amount ofan obeticholic acid composition described above. In yet anotherembodiment, the method is a method of treating cirrhosis byadministering an effective amount of an obeticholic acid compositiondescribed above.

NAFLD is a medical condition that is characterized by the buildup of fat(called fatty infiltration) in the liver. NAFLD is one of the mostcommon causes of chronic liver disease, and encompasses a spectrum ofconditions associated with lipid deposition in hepatocytes. It rangesfrom steatosis (simple fatty liver), to nonalcoholic steatohepatitis(NASH), to advanced fibrosis and cirrhosis. The disease is mostly silentand is often discovered through incidentally elevated liver enzymelevels. NAFLD is strongly associated with obesity and insulin resistanceand is currently considered by many as the hepatic component of themetabolic syndrome.

Nonalcoholic steatohepatitis (NASH) is a condition that causesinflammation and accumulation of fat and fibrous (scar) tissue in theliver. Liver enzyme levels in the blood may be more elevated than themild elevations seen with nonalcoholic fatty liver (NAFL). Althoughsimilar conditions can occur in people who abuse alcohol, NASH occurs inthose who drink little to no alcohol. NASH affects 2 to 5 percent ofAmericans, and is most frequently seen in people with one of more of thefollowing conditions: obesity, diabetes, hyperlipidemia, insulinresistance, uses of certain medications, and exposure to toxins. NASH isan increasingly common cause of chronic liver disease worldwide and isassociated with increased liver-related mortality and hepatocellularcarcinoma, even in the absence of cirrhosis. NASH progresses tocirrhosis in 15-20% of affected individuals and is now one of theleading indications for liver transplantation in the United States. Atpresent there are no approved therapies for NASH.

In one embodiment, the method is a method of treating NASH byadministering an obeticholic acid composition described herein,optionally in a titration period as described herein. The NASH patientcan be a high risk NASH patient. A “high risk NASH patient” refers tocharacterization by one or more of: NAS≧4; baseline fibrosis stage 2 or3; or baseline fibrosis stage 1 with a comorbidity (type 2 diabetes,BMI≧30 kg/m2 or ALT≧60 U/L).

In one embodiment, the disease or condition is hyperlipidemia. In oneembodiment, the disease or condition is a cholestatic liver disease. Inone embodiment, the disease or condition is PBC. In another embodiment,the disease or condition is a cardiovascular disease. In anotherembodiment, the cardiovascular disease is atherosclerosis,hypercholesteremia, or hypertriglyceridemia.

The present disclosure also provides a method for treating or preventingNAFLD or NASH. In one embodiment, the present disclosure provides amethod for treating or preventing NAFLD or NASH that is associated withhyperlipidemia. In one embodiment, the present disclosure provides amethod for treating or preventing NASH. In one embodiment, the presentdisclosure provides a method for treating or preventing NASH that isassociated with hyperlipidemia.

In another aspect, the present disclosure also provides a method fordecreasing liver enzymes, comprising administering a therapeuticallyeffective amount of the composition of the present disclosure to asubject in need thereof. In one embodiment, the subject is not sufferingfrom a cholestatic condition. In another embodiment, the subject issuffering from a cholestatic condition. In one embodiment, the liverenzyme is alkaline phosphatase, 7-glutamyl transpeptidase (GGT), and/or5′ nucleotidase.

In certain instances, the methods described herein also includeassessing, monitoring, measuring, or otherwise detecting liver function.Assessing, monitoring, measuring, or otherwise detecting liver functioncan be performed before, during, or after a titration period describedherein, or in other instances, performed during the course of anytreatment described herein. Liver function can be determined by, forexample, assessing, monitoring, measuring, or otherwise detecting alevel of one or more liver biomarkers compared to a control. In certaininstances the control is a baseline taken from the patient beforebeginning treatment. In other instances the control is preestablishedbaseline considered as a normal value.

Values for measure or detection of liver function biomarkers andcontrols can be expressed as a comparison to Upper Limit of Normal(ULN).

Liver biomarkers can be used to ascertain, quantify the efficacy of thecourse of treatment with an obeticholic acid composition describedherein. In other instances, liver biomarkers described herein can beused to ascertain, quantify liver function during the course oftreatment with an obeticholic acid composition described herein. Liverbiomarkers can also be used to predict whether a patient or patientpopulation will be susceptible to treatment with an obeticholic acidcomposition described herein. In one embodiment, the liver biomarkersinclude assessing, monitoring, measuring or otherwise detecting anamount or level of aspartate transaminase (AST), alanine transaminase(ALT), alkaline phosphatase (ALP), bilirubin, glycine conjugatedobeticholic acid, taurine conjugated obeticholic acid, a bile acid, abile acid glycine conjugate, or a bile acid taurine conjugate. Forexample, the liver biomarker assessed, monitored, measured, or detectedcan be ALP.

The ALP level can be a measure of ULN. In one embodiment, a patientbefore treatment can have an ALP level of at least 1.1×ULN to at least20×ULN; at least 1.1×ULN to at least 15×ULN; at least 1.1×ULN to atleast 12×ULN; at least 1.1×ULN to at least 10×ULN; at least 1.1×ULN toat least 8×ULN; at least 1.1×ULN to at least 6×ULN; at least 1.1×ULN toat least 5×ULN; at least 1.1×ULN to at least 4×ULN; at least 1.1×ULN toat least 3×ULN; or at least 1.1×ULN to at least 2×ULN.

A patient before a treatment described herein can have an ALP level ofabout 1.5×ULN to about 20×ULN; about 1.5×ULN to about 15×ULN; about1.5×ULN to about 10 ULN; about 1.5×ULN to about 5×ULN; or about 1.5×ULNto about 3×ULN. A patient before treatment can have an ALP level beforea treatment described herein of about 1.5×, 2×, 3×, 4×, 5×, 8×, 10×,15×, or 20×ULN.

A patient before treatment can have an ALP level before a treatmentdescribed herein of greater than about 1.5×, 2×, 3×, 4×, 5×, 8×, 10×,15×, or 20×ULN. In one embodiment, a patient has an ALP level of about1.5×ULN. In one embodiment, a patient has an ALP level of about 2×ULN.In one embodiment, a patient has a ALP level of about 5×ULN. In oneembodiment, a patient has an ALP level of about 10×ULN. In oneembodiment, a patient has a bilirubin level of about 15×ULN. In oneembodiment, a patient has an ALP level greater than about 1.5×ULN. Inone embodiment, a patient has an ALP level greater than about 2×ULN. Inone embodiment, a patient has a ALP level greater than about 5×ULN. Inone embodiment, a patient has an ALP level greater than about 10×ULN. Inone embodiment, a patient has a bilirubin level greater than about15×ULN.

In another example, the liver biomarker assessed, monitored, measured,or detected can be bilirubin. The bilirubin level can be a measure ofULN. In one embodiment, a patient before treatment can have a bilirubinlevel of at least 1.1×ULN to at least 20×ULN; at least 1.1×ULN to atleast 15×ULN; at least 1.1×ULN to at least 12×ULN; at least 1.1×ULN toat least 10×ULN; at least 1.1×ULN to at least 8×ULN; at least 1.1×ULN toat least 6×ULN; at least 1.1×ULN to at least 5×ULN; at least 1.1×ULN toat least 4×ULN; at least 1.1×ULN to at least 3×ULN; or at least 1.1×ULNto at least 2×ULN.

A patient before a treatment described herein can have a bilirubin levelof about 1.5×ULN to about 20×ULN; about 1.5×ULN to about 15×ULN; about1.5×ULN to about 10 ULN; about 1.5×ULN to about 5×ULN; or about 1.5×ULNto about 3×ULN. In another example a patient before a treatmentdescribed herein can have a bilirubin level of about 2×ULN to about20×ULN; about 2×ULN to about 15×ULN; about 2×ULN to about 10 ULN; about2×ULN to about 5×ULN; or about 2×ULN to about 3×ULN. In another examplea patient before a treatment described herein can have a bilirubin levelof greater than about 2×ULN to greater than about 20×ULN; greater thanabout 2×ULN to greater than about 15×ULN; greater than about 2×ULN togreater than about 10 ULN; greater than about 2×ULN to greater thanabout 5×ULN; or greater than about 2×ULN to greater than about 3×ULN.

A patient before treatment can have a bilirubin level before a treatmentdescribed herein of about 1.5×, 2×, 3×, 4×, 5×, 8×, 10×, 15×, or 20×ULN.A patient before treatment can have a bilirubin level before a treatmentdescribed herein of greater than about 1.5×, 2×, 3×, 4×, 5×, 8×, 10×,15×, or 20×ULN. In one embodiment, a patient has a bilirubin levelgreater than about 2×ULN. In one embodiment, a patient has a bilirubinlevel greater than about 5×ULN. In one embodiment, a patient has abilirubin level greater than about 10×ULN. In one embodiment, a patienthas a bilirubin level greater than about 15×ULN. In one embodiment, apatient has a bilirubin level less than about 2×ULN. In one embodiment,a patient has a bilirubin level less than about 5×ULN. In oneembodiment, a patient has a bilirubin level less than about 10×ULN. Inone embodiment, a patient has a bilirubin level less than about 15×ULN.

In some instances it can be useful to assess, monitor, measure, ordetect ALP and bilirubin to assess, monitor, measure, or otherwisedetect liver function or changes in liver function during treatment withan obeticholic acid composition described herein. In certain instances,a patient has an ALP level as provided above (e.g., about 1.5×ULN toabout 10×ULN) and a bilirubin level as provided above (e.g., less thanabout 5×ULN). In one embodiment, the patient has an ALP level betweenabout 1.5×ULN to about 10×ULN and a bilirubin level less than about2×ULN.

Treatment with a obeticholic acid composition described herein canreduce the levels of ALP and/or bilirubin in a patient described herein.For example, treatment of a disease or condition described herein (e.g.,PBC) with an obeticholic acid composition described herein can reducethe level of ALP by 2, 4, 5, 6, 8, 9, 10, 12, 15, 18, 20, 21, 22, 23,24, 25, 26, 27, 28, 29, 30, 35, 40, 45, 50, 55, 60, 65, 70, 75, 80, 85,88, 90, 92, 94, 96, 97, 98, 99, 99.2, 99.4, 99.6, 99.7, 99.8, 99.9, or100%. In another example, the level of ALP can be reduced by at least100%, at least 125%, at least 150%, at least 175%, at least 200%, atleast 225%, at least 250% or at least 300%.

In another example, the level of ALP can be reduced by about 5% to about50%; about 10% to about 55%; about 10% to about 45%; about 10% to about40%; about 10% to about 33%, about 10% to about 30%; about 15% to about30%; about 15% to about 25%; about 20% to about 50%, about 20% to about40%; about 20% to about 35%; about 20% to about 30%; 20% to about 27%;or about 20% to about 27%. In another example, the level of ALP can bereduced by at least 50%. The level of ALP can be reduced by at least40%. The level of ALP can be reduced by at least 35%. The level of ALPcan be reduced by at least 30%. The level of ALP can be reduced by atleast 27%. The level of ALP can be reduced by at least 25%. The level ofALP can be reduced by at least 20%.

The reduction of ALP levels can be represented by the fold change overULN. For example, treatment with an obeticholic acid described hereincan reduce the ALP level of a patient described herein to less thanabout 5×ULN; less than about 4×ULN, less than about 3×ULN, less thanabout 2×ULN, less than about 1.7×ULN, less than about 1.5×ULN, less thanabout 1.25×ULN, or less than about ULN.

In another example, the ALP level is reduced by at least 1, 2, 3, 4, 5,6, 7, 8, 9, 10, 15, 20, 25, 30, 40, or 50 fold compared to a baselinevalue. For example, the ALP level after treatment with an obeticholicacid composition described herein can be reduced by 1, 1.2, 1.4, 1.6,1.8, or 2 fold, including intervening values therein, compared to abaseline value. In another example, the ALP level can be reduced by 2,2.2, 2.4, 2.6, 2.8, or 3 fold, including intervening values therein,compared to a baseline value. In another example, the ALP level can bereduced 3, 4, or 5 fold, including intervening values therein, comparedto a baseline value. In another example, the ALP level can be reduced 5,7, 9, or 10 fold, including intervening values therein, compared to abaseline value. In another example, the ALP level can be reduced 10, 12,15, or 20 fold, including intervening values therein, compared to abaseline value.

Treatment of a disease or condition described herein (e.g., PBC) with anobeticholic acid composition described herein can reduce the level ofbilirubin by 2, 4, 5, 6, 8, 9, 10, 12, 15, 18, 20, 21, 22, 23, 24, 25,26, 27, 28, 29, 30, 35, 4-, 45, 50, 55, 60, 65, 70, 75, 80, 85, 88, 90,92, 94, 96, 97, 98, 99, 99.2, 99.4, 99.6, 99.7, 99.8, 99.9, or 100%. Inanother example, the level of bilirubin can be reduced by at least 100%,at least 125%, at least 150%, at least 175%, at least 200%, at least225%, at least 250% or at least 300%.

In another example, the level of bilirubin can be reduced by about 5% toabout 50%; about 10% to about 55%; about 10% to about 45%; about 10% toabout 40%; about 10% to about 33%, about 10% to about 30%; about 15% toabout 30%; about 15% to about 25%; about 20% to about 50%, about 20% toabout 40%; about 20% to about 35%; about 20% to about 30%; 20% to about27%; or about 20% to about 27%. In another example, the level ofbilirubin can be reduced by at least 50%. The level of bilirubin can bereduced by at least 40%. The level of bilirubin can be reduced by atleast 35%. The level of bilirubin can be reduced by at least 30%. Thelevel of bilirubin can be reduced by at least 27%. The level ofbilirubin can be reduced by at least 25%. The level of bilirubin can bereduced by at least 20%.

The reduction of bilirubin levels can be represented by the fold changeover ULN. For example, treatment with an obeticholic acid describedherein can reduce the bilirubin level of a patient described herein toless than about 5×ULN; less than about 4×ULN, less than about 3×ULN,less than about 2×ULN, less than about 1.7×ULN, less than about 1.5×ULN,less than about 1.25×ULN, or less than about ULN.

In another example, the bilirubin level is reduced by at least 1, 2, 3,4, 5, 6, 7, 8, 9, 10, 15, 20, 25, 30, 40, or 50 fold compared to abaseline value. For example, the bilirubin level after treatment with anobeticholic acid composition described herein can be reduced by 1, 1.2,1.4, 1.6, 1.8, or 2 fold, including intervening values therein, comparedto a baseline value. In another example, the bilirubin level can bereduced by 2, 2.2, 2.4, 2.6, 2.8, or 3 fold, including interveningvalues therein, compared to a baseline value. In another example, thebilirubin level can be reduced 3, 4, or 5 fold, including interveningvalues therein, compared to a baseline value. In another example, thebilirubin level can be reduced 5, 7, 9, or 10 fold, includingintervening values therein, compared to a baseline value. In anotherexample, the bilirubin level can be reduced 10, 12, 15, or 20 fold,including intervening values therein, compared to a baseline value.

In another embodiment, one or more biomarkers can stratify a patientpopulation undergoing or who will undergo treatment with an obeticholicacid composition described herein. For example, a PBC patient can bestratified for the risk of hepatocellular carcinoma (HCC).

In yet another embodiment, liver biomarkers useful for detection caninclude metabolites and bile acids. For example, assessing, monitoring,measuring, or otherwise detecting levels of glycine and taurineconjugates of obeticholic acid can be useful for measuring efficacy of atreatment regimen described herein. For example, assessing, monitoring,measuring, or otherwise detecting levels or detecting plasma levels ofbile acids including cholic acid, chenodeoxycholic acid, deoxycholicacid, lithocholic acid, and urosodeoxycholic acid, including glycine andtaurine conjugates thereof, and optionally comparing the levels to acontrol, can be useful for measuring efficacy of a treatment regimendescribed herein.

In still other embodiments, calculating an AST to platelet index (APRI)can be useful for assessing, monitoring, measuring, or otherwisedetecting liver function (including changes thereof). The obeticholicacid compositions described herein can reduce the APRI of a patientdescribed herein. In certain instances, monitoring or measuring the APRIcan be used to determine efficacy of treatment with an obeticholic acidcomposition described herein. In some embodiments, a reduction in APRIis observed in a patient (e.g., a PBC or NASH patient) afteradministration of an obeticholic acid composition described herein. Forexample, the APRI may be reduced by about 5% to about 50% in patientstreated with obeticholic acid relative to baseline levels measuredbefore dose administration. The reduction may be up to about 5%, 10%,15%, 20%, 25%, 30%, 35%, 40%, 45% or 50%.

Further provided herein is a method for treating PBC in a patient inneed thereof by administering a starting dose of an obeticholic acidcomposition described herein in a titration period. The method includesassessing liver function of the patient before, during, and after saidtitration period by either calculating an APRI score for said patient;or by measuring the level of one or more liver biomarker selected fromALP, bilirubin, AST, ALT, glycine conjugated obeticholic acid, taurineconjugated obeticholic acid, a bile acid, a bile acid glycine conjugate,or a bile acid taurine conjugate, where a reduced APRI score compared toa control or a reduced level of the one or more liver biomarkerscompared to a control indicates non-impaired liver function. The methodfurther includes assessing tolerance of the patient to the starting doseby grading the severity of one or more adverse effects, if present, andadministering an adjusted dose of the obeticholic acid composition,where the adjusted dose includes an amount equal to or greater than anamount of the starting dose. The starting dose, adjusted dose, andtitration period are as described below. For example, the starting dosecan be about 5 to about 50 mg (e.g., 5 mg) and the adjusted dose can beabout 5 to about 50 mg (e.g., 5 mg, 10 mg, or 25 mg) and the titrationperiod can be a time of about 1 to about 6 months, e.g., 1 month, 2months, 3 months, 4 months, 5 months, or 6 months.

Also provided herein are methods to reduce or eliminate rejectionfailure of a liver transplant by administering an effective amount of anobeticholic acid composition described above. In certain instancesadministration of an obeticholic acid composition described hereinreduces expression or levels of ALP and/or bilirubin. In one embodiment,administration of an obeticholic acid composition described hereinreduces ALP and bilirubin levels, thereby reducing transplantcomplications or rejection. In another embodiment, administration of aneffective amount of an obeticholic acid composition described hereinincreases post-transplantation survival rate of a liver transplantee.

In one aspect, obeticholic acid may mediate its action primarily via FXRagonism, wherein FGF-19 released from gut enterocytes (in response toFXR agonist) into portal circulation down regulates endogenous bile acidsynthesis in the liver. The present disclosure comprehends a method ofmeasuring FXR agonist activity by, for example, measuring release ofFGF-19 into the bloodstream or circulation of a patient administeredwith OCA. Levels of FGF-19 may be measured by methods known in the art,such as those described herein.

Obeticholic acid administration may lead to a significant and adose-dependent increase in the levels of FGF-19 and in some embodiments,a decrease in the levels of endogenous bile acids and C4 (a bile acidprecursor). In some embodiments, a significant increase in FGF-19 levelsmay be observed from baseline to month 3, month 6 and month 12 afterdose administration. In some examples, the FGF-19 levels may increasefrom about 5% to about 200%. In specific embodiments, the levels mayincrease by about 5%, 10%, 15%, 20%, 25%, 30%, 35%, 40%, 45%, 50%, 55%,60%, 65%, 70%, 75%, 80%, 85%, 90%, 95% or 100%.

In some embodiments, the plasma levels of FGF-19, a marker of FXRactivation, are determined using a qualified method and a validatedmethod using an enzyme-linked immunosorbent assay (ELISA) method. Theplasma concentrations of FGF-19 may be quantitated at predose and afteradministration of dose.

In some examples, a monoclonal antibody specific for FGF-19 ispre-coated onto a microplate. Standards, quality controls and samplesare pipetted into the wells and any FGF-19 present is bound by theimmobilized antibody. After washing away any unbound substances, anenzyme-linked polyclonal antibody specific for FGF-19 is added to thewells. Following a wash to remove any unbound antibody-enzyme reagent, asubstrate solution is added to the wells and color develops in theproportion to the amount of FGF-19 bound in the initial step. The colordevelopment is stopped and the intensity of the color is measured. Thecalibration range of the method is 15.625 pg/ml to 1000 pg/ml for FGF-19using a 100 μl aliquot of standard curve, quality control and sample. Insome embodiments, no minimum required dilution is used. In otherembodiments, samples may be subjected to a 3× minimum required dilution.

Also provided herein are methods to reduce or eliminate rejectionfailure of a liver transplant by administering an effective amount of anobeticholic acid composition described above. In certain instances,administration of an obeticholic acid composition described hereinreduces expression or levels of ALP and/or bilirubin. In one embodiment,administration of an obeticholic acid composition described hereinreduces ALP and bilirubin levels, thereby reducing transplantcomplications or rejection. In another embodiment, administration of aneffective amount of an obeticholic acid composition described hereinincreases post-transplantation survival rate of a liver transplantee.

In another aspect of the disclosure is a method of treating asolid-tumor cancer by administering an effective amount of anobeticholic acid composition as described herein. In another aspect,such methods include treating hepatocellular carcinoma (HCC), colorectalcancer, gastric cancer, liver cancer, breast cancer, renal cancer, orpancreatic cancer by administering an obeticholic acid composition asdescribed herein. In one embodiment is a method of treating HCC byadministering an effective amount of an obeticholic acid composition asdescribed herein. In one embodiment is a method of treating colorectalcancer by administering an effective amount of an obeticholic acidcomposition as described herein. In another embodiment is a method oftreating gastric cancer by administering an effective amount of anobeticholic acid composition as described herein. In another embodimentis a method of treating liver cancer by administering an effectiveamount of an obeticholic acid composition as described herein. In stillanother embodiment is a method of treating renal cancer by administeringan effective amount of an obeticholic acid composition as describedherein. In still another embodiment is a method of treating pancreaticcancer by administering an effective amount of an obeticholic acidcomposition as described herein. It is understood that the treatment ofa cancer described herein can be performed by administering an effectiveamount of an obeticholic acid composition described herein incombination with one or more anticancer agents, such as those describedherein. In some embodiments, the effective amount administered is astarting dose as described herein.

Still further provided herein are methods of treating an autoimmunedisease in a patient in need thereof by administering an effectiveamount of an obeticholic acid composition as described herein. In oneinstance, the autoimmune disease is selected from multiple sclerosis,rheumatoid arthritis, and type I diabetes. In one embodiment is a methodof treating multiple sclerosis by administering an effective amount ofan obeticholic acid composition as described herein. In anotherembodiment is a method of treating rheumatoid arthritis by administeringan effective amount of an obeticholic acid composition as describedherein. In still another embodiment is a method of treating type Idiabetes by administering an effective amount of an obeticholic acidcomposition as described herein. In certain instances, the treatment ofthe autoimmune disease includes further administering another activeagent useful for the treatment, such as without limitation,non-steroidal anti-inflammatory agents (NSAIDs) such as ibuprofen,naproxen, corticosteroids, disease-modifying anti-rheumatic drugs suchas methotrexate (Trexall, Otrexup, Rasuvo), leflunomide (Arava),hydroxychloroquine (Plaquenil) and sulfasalazine (Azulfidine), biologicagents such as abatacept (Orencia), adalimumab (Humira), anakinra(Kineret), certolizumab (Cimzia), etanercept (Enbrel), golimumab(Simponi), infliximab (Remicade), rituximab (Rituxan), tocilizumab(Actemra) and tofacitinib (Xeljanz), interferons, such as interferonalpha, interferon beta, interferon gamma, and PEGylated versionsthereof, glatiramer acetate (also known in the art as Copaxone),dimethyl fumarate (also known in the art as Tecfidera), fingolimod (alsoknown in the art as Gilenya), teriflunomide (also known in the art asAubagio), natalizumab (also known in the art as Tysabri), alemtuzumab(also known in the art as Lemtrada), and mitoxantrone. For example, anobeticholic acid composition described herein can be administered incombination with metformin, insulin, insulin mimetic, or any other knownanti-diabetic or anti-glycemic agent for treatment of diabetes. In someembodiments, the effective amount administered is a starting dose asdescribed herein.

In another aspect, the present disclosure also provides a method forinhibiting or reversing fibrosis, comprising administering atherapeutically effective amount of the composition of the presentdisclosure to a subject in need thereof. In one embodiment, the subjectis not suffering from a cholestatic condition. In another embodiment,the subject is suffering from a cholestatic condition.

In one embodiment, the subject is not suffering from a cholestaticcondition associated with a disease or condition selected from the groupconsisting of cancers, such as, e.g., cancers as described herein,including primary liver and biliary cancer, metastatic cancer, sepsis,chronic total parenteral nutrition, cystic fibrosis, and granulomatousliver disease. In embodiments, the fibrosis to be inhibited occurs in anorgan where FXR is expressed.

In one embodiment, a cholestatic condition is defined as having anabnormally elevated serum level of alkaline phosphatase, 7-glutamyltranspeptidase (GGT), and/or 5′ nucleotidase. In another embodiment, acholestatic condition is further defined as presenting with at least oneclinical symptom. In one embodiment, the symptom is itching (pruritus).In another embodiment, a cholestatic condition is selected from thegroup consisting of primary biliary cirrhosis (PBC), primary sclerosingcholangitis (PBS), biliary atresia, drug-induced cholestasis, hereditarycholestasis, and intrahepatic cholestasis of pregnancy.

In one embodiment, the fibrosis is selected from the group consisting ofliver fibrosis, kidney fibrosis, and intestinal fibrosis.

In one embodiment, the subject has liver fibrosis associated with adisease selected from the group consisting of hepatitis B; hepatitis C;parasitic liver diseases; post-transplant bacterial, viral and fungalinfections; alcoholic liver disease (ALD); non-alcoholic fatty liverdisease (NAFLD); non-alcoholic steatohepatitis (NASH); liver diseasesinduced by methotrexate, isoniazid, oxyphenistatin, methyldopa,chlorpromazine, tolbutamide, or amiodarone; autoimmune hepatitis;sarcoidosis; Wilson's disease; hemochromatosis; Gaucher's disease; typesIII, IV, VI, IX and X glycogen storage diseases; α₁-antitrypsindeficiency; Zellweger syndrome; tyrosinemia; fructosemia; galactosemia;vascular derangement associated with Budd-Chiari syndrome,veno-occlusive disease, or portal vein thrombosis; and congenitalhepatic fibrosis.

In another embodiment, the subject has intestinal fibrosis associatedwith a disease selected from the group consisting of Crohn's disease,ulcerative colitis, post-radiation colitis, and microscopic colitis.

In another embodiment, the subject has renal fibrosis associated with adisease selected from the group consisting of diabetic nephropathy,hypertensive nephrosclerosis, chronic glomerulonephritis, chronictransplant glomerulopathy, chronic interstitial nephritis, andpolycystic kidney disease.

In another aspect, the present disclosure also provides a method fortreating or preventing all forms of conditions related to elevated lipidlevels. In one embodiment, the condition is hyperlipidemia where it isassociated with a condition selected from resistant primary biliarycirrhosis; primary biliary cirrhosis where there is associated liverfunction test elevation and hyperlipidemia, primary sclerosingcholangitis, non-alcohol-induced steatohepatitis; and chronic liverdisease associated with hepatitis B, C or alcohol. In anotherembodiment, the present disclosure provides a method for treating orpreventing hyperlipidemia, where the hyperlipidemia is primaryhyperlipidemia with or without a genetic component, or hyperlipidemiaassociated with coronary artery disease, cerebrovascular arterialdisease, peripheral vascular disease, aortic aneurisms, or carotidatherosclerosis.

In one aspect, the present disclosure provides a method for treating orpreventing primary sclerosing cholangitis for similar biochemicalabnormalities, as well as chronic hepatitis caused by hepatitis B, C orby alcohol. In one aspect, the present disclosure provides a method fortreating or preventing other arterial disorders associated withhyperlipidemia. In one aspect, the present disclosure provides a methodfor treating or preventing hypertriglyceridemia.

Therapies with FXR agonists may produce various side effects, one ofwhich is pruritus. Pruritus or itch is defined as an unpleasantsensation of the skin that provokes the urge to scratch. It is acharacteristic feature of many skin diseases and an unusual sign of somesystemic diseases. Pruritus may be localized or generalized and canoccur as an acute or chronic condition. Itching lasting more than 6weeks is termed chronic pruritus. Itching can be intractable andincapacitating, as well as a diagnostic and therapeutic challenge.

One of the advantages of the compositions of the present disclosureincludes a decrease in the incidence and/or severity of pruritus insubjects treated with the compositions and according to the methods ofthe present disclosure.

In one embodiment, the incidence of pruritus decreases by at least 5%,10%, 15%, 20%, 25%, 30%, 35%, 40%, 45%, or 50% in subjects treated withthe compositions of the present disclosure. In a further embodiment, theincidence of pruritus decreases by at least 20%, 25%, 30%, 35%, 40%,45%, or 50% in subjects treated with the compositions of the presentdisclosure. In a further embodiment, the incidence of pruritus decreasesby at least 5%, 10%, 15%, 20%, 25%, 30%, 35%, 40%, 45%, or 50% insubjects treated with the compositions of the present disclosure duringthe first one month, two months, three months, four months, five months,or six months after the beginning of the treatment. In a furtherembodiment, the incidence of pruritus decreases by at least 20%, 25%,30%, 35%, 40%, 45%, or 50% in subjects treated with the compositions ofthe present disclosure during the first one month, two months, threemonths, four months, five months, or six months after the beginning ofthe treatment.

In one embodiment, the severity of the pruritus decreases by at least5%, 10%, 15%, 20%, 25%, 30%, 35%, 40%, 45%, or 50% in subjects treatedwith the compositions of the present disclosure. In a furtherembodiment, the severity of pruritus decreases by at least 20%, 25%,30%, 35%, 40%, 45%, or 50% in subjects treated with the compositions ofthe present disclosure. In a further embodiment, the severity ofpruritus decreases by at least 5%, 10%, 15%, 20%, 25%, 30%, 35%, 40%,45%, or 50% in subjects treated with the compositions of the presentdisclosure during the first one month, two months, three months, fourmonths, five months, or six months after the beginning of the treatment.In a further embodiment, the severity of pruritus decreases by at least20%, 25%, 30%, 35%, 40%, 45%, or 50% in subjects treated with thecompositions of the present disclosure during the first one month, twomonths, three months, four months, five months, or six months after thebeginning of the treatment.

Obeticholic acid compositions described herein can be administered to apatient in an amount of between about: 1 mg to about 50 mg; 1 to about40 mg; 1 to about 30 mg; 1 to about 25 mg; 1 to about 20 mg; 1 mg toabout 10 mg; or 1 mg to about 5 mg. In one embodiment, the obeticholicacid composition can be administered to a patient in an amount of about:5 to about 50 mg; 5 to about 40 mg; 5 to about 30 mg; 5 to about 25 mg;5 to about 20 mg; or 5 to about 10 mg. In other instances, theobeticholic acid composition can be administered in an amount of about1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20,21, 22, 23, 24, 25, 30, 35, 40, 45, or 50 mg. In still other instances,the obeticholic acid composition described herein can be administered atan amount of about 5 mg, 10 mg, 15 mg, 25 mg, or 50 mg. For example, aneffective amount of a obeticholic acid composition described herein canbe about 5 mg, 10 mg, 25 mg, or 50 mg. In another example, the amount ofa starting dose of an obeticholic acid composition described herein canbe about 5 mg, 10 mg, 25 mg, or 50 mg. In another example, the amount ofan adjusted dose or re-adjusted dose of an obeticholic acid compositiondescribed herein can be about 5 mg, 10 mg, 25 mg, or 50 mg. It is to beunderstood the amount of an obeticholic acid composition describedherein as administered to a patient described herein refers to theamount of obeticholic acid in the composition.

The amount of an obeticholic acid composition as provided above canrefer to an effective amount as described herein. In certainembodiments, an effective amount of the obeticholic acid compositionadministered to a patient described herein can be 5 mg. In anotherembodiment, an effective amount of the obeticholic acid compositionadministered to a patient described herein can be 10 mg. In stillanother embodiment, an effective amount of the obeticholic acidcomposition administered to a patient described herein can be 25 mg. Inyet another embodiment, an effective amount of the obeticholic acidcomposition administered to a patient described herein can be 50 mg.

The amount of an obeticholic acid composition as provided above canoptionally refer to a starting dose administered during a titrationperiod as described herein. In certain embodiments, a starting dose ofthe obeticholic acid composition administered to a patient describedherein can be 5 mg. In another embodiment, a starting dose of theobeticholic acid composition administered to a patient described hereincan be 10 mg. In still another embodiment, a starting dose of theobeticholic acid composition administered to a patient described hereincan be 25 mg. In yet another embodiment, a starting dose of theobeticholic acid composition administered to a patient described hereincan be 50 mg.

The amount of an obeticholic acid composition as provided above canrefer to an adjusted dose administered after a titration period asdescribed herein. In certain embodiments, an adjusted dose of theobeticholic acid composition administered to a patient described hereincan be 5 mg. In another embodiment, an adjusted dose of the obeticholicacid composition administered to a patient described herein can be 10mg. In still another embodiment, an adjusted dose of the obeticholicacid composition administered to a patient described herein can be 25mg. In yet another embodiment, an adjusted dose of the obeticholic acidcomposition administered to a patient described herein can be 50 mg.

The amount of an obeticholic acid composition as provided above canrefer to a re-adjusted dose administered after a titration period asdescribed herein. In certain embodiments, a re-adjusted dose of theobeticholic acid composition administered to a patient described hereincan be 5 mg. In another embodiment, a re-adjusted dose of theobeticholic acid composition administered to a patient described hereincan be 10 mg. In still another embodiment, a re-adjusted dose of theobeticholic acid composition administered to a patient described hereincan be 25 mg. In yet another embodiment, a re-adjusted dose of theobeticholic acid composition administered to a patient described hereincan be 50 mg.

While it is possible to administer obeticholic acid directly without anyformulation, obeticholic acid is usually administered in the form ofpharmaceutical formulations comprising a pharmaceutically acceptableexcipient and obeticholic acid. These formulations can be administeredby a variety of routes including oral, buccal, rectal, intranasal,transdermal, subcutaneous, intravenous, intramuscular, and intranasal.Oral formulation of obeticholic acid are described further herein underthe section entitled “Oral Formulation and Administration”.

In one embodiment, obeticholic acid can be administered transdermally.In order to administer transdermally, a transdermal delivery device(“patch”) is needed. Such transdermal patches may be used to providecontinuous or discontinuous infusion of a compound of the presentdisclosure in controlled amounts. The construction and use oftransdermal patches for the delivery of pharmaceutical agents is wellknown in the art. See, e.g., U.S. Pat. No. 5,023,252. Such patches maybe constructed for continuous, pulsatile, or on demand delivery ofpharmaceutical agents.

Pharmaceutical compositions suitable for injectable use include sterileaqueous solutions (where water soluble) or dispersions and sterilepowders for the extemporaneous preparation of sterile injectablesolutions or dispersion. For intravenous administration, suitablecarriers include physiological saline, bacteriostatic water, CremophorEL™ (BASF, Parsippany, N.J.) or phosphate buffered saline (PBS). In allcases, the composition must be sterile and should be fluid to the extentthat easy syringeability exists. It must be stable under the conditionsof manufacture and storage and must be preserved against thecontaminating action of microorganisms such as bacteria and fungi. Thecarrier can be a solvent or dispersion medium containing, for example,water, ethanol, polyol (for example, glycerol, propylene glycol, andliquid polyethylene glycol, and the like), and suitable mixturesthereof. The proper fluidity can be maintained, for example, by the useof a coating such as lecithin, by the maintenance of the requiredparticle size in the case of dispersion and by the use of surfactants.Prevention of the action of microorganisms can be achieved by variousantibacterial and antifungal agents, for example, parabens,chlorobutanol, phenol, ascorbic acid, thimerosal, and the like. In manycases, it will be preferable to include isotonic agents, for example,sugars, polyalcohols such as mannitol, sorbitol, sodium chloride in thecomposition. Prolonged absorption of the injectable compositions can bebrought about by including in the composition an agent which delaysabsorption, for example, aluminum monostearate and gelatin.

Sterile injectable solutions can be prepared by incorporating the activecompound, obeticholic acid or obeticholic acid particles, in therequired amount in an appropriate solvent with one or a combination ofingredients enumerated herein, as required, followed by filteredsterilization. Generally, dispersions are prepared by incorporating theobeticholic acid into a sterile vehicle that contains a basic dispersionmedium and the required other ingredients from those enumerated above.In the case of sterile powders for the preparation of sterile injectablesolutions, methods of preparation are vacuum drying and freeze-dryingthat yields a powder of the obeticholic acid or obeticholic acidparticles, plus any additional desired ingredient from a previouslysterile-filtered solution thereof.

It can be useful to orally administer an obeticholic acid compositiondescribed herein. Oral compositions generally include an inert diluentor an edible pharmaceutically acceptable carrier. They can be enclosedin gelatin capsules or compressed into tablets. For the purpose of oraltherapeutic administration, the active compound, obeticholic acid orobeticholic acid particles, can be incorporated with excipients and usedin the form of tablets, troches, or capsules. Oral compositions can alsobe prepared using a fluid carrier for use as a mouthwash, wherein theobeticholic acid or obeticholic acid particles in the fluid carrier isapplied orally and swished and expectorated or swallowed.Pharmaceutically compatible binding agents, and/or adjuvant materialscan be included as part of the composition. The tablets, pills,capsules, troches and the like can contain any of the followingingredients, or compounds of a similar nature: a binder such asmicrocrystalline cellulose, gum tragacanth or gelatin; an excipient suchas sodium starch glycolate, starch or lactose, a diluent such asmicrocrystalline cellulose, a disintegrating agent such as alginic acid,Primogel, or corn starch; a lubricant such as magnesium stearate orSterotes; a glidant such as colloidal silicon dioxide; a sweeteningagent such as sucrose or saccharin; or a flavoring agent such aspeppermint, methyl salicylate, or orange flavoring.

For administration by inhalation, the obeticholic acid or obeticholicacid particles is delivered in the form of an aerosol spray frompressured container or dispenser, which contains a suitable propellant,e.g., a gas such as carbon dioxide, or a nebulizer.

Systemic administration can also be by transmucosal or transdermalmeans. For transmucosal or transdermal administration, penetrantsappropriate to the barrier to be permeated are used in the formulation.Such penetrants are generally known in the art, and include, forexample, for transmucosal administration, detergents, bile salts, andfusidic acid derivatives. Transmucosal administration can beaccomplished through the use of nasal sprays or suppositories. Fortransdermal administration, the obeticholic acid or obeticholic acidparticles is formulated into ointments, salves, gels, or creams asgenerally known in the art.

The obeticholic acid or obeticholic acid particles can be prepared withpharmaceutically acceptable carriers that will protect the compoundagainst rapid elimination from the body, such as a controlled releaseformulation, including implants and microencapsulated delivery systems.Biodegradable, biocompatible polymers can be used, such as ethylenevinyl acetate, polyanhydrides, polyglycolic acid, collagen,polyorthoesters, and polylactic acid. Methods for preparation of suchformulations will be apparent to those skilled in the art. The materialscan also be obtained commercially from Alza Corporation and NovaPharmaceuticals, Inc. Liposomal suspensions (including liposomestargeted to infected cells with monoclonal antibodies to viral antigens)can also be used as pharmaceutically acceptable carriers. These can beprepared according to methods known to those skilled in the art, forexample, as described in U.S. Pat. No. 4,522,811.

It is especially advantageous to formulate oral or parenteralcompositions in dosage unit form for ease of administration anduniformity of dosage. Dosage unit form as used herein refers tophysically discrete units suited as unitary dosages for the subject tobe treated; each unit containing a predetermined quantity of obeticholicacid or obeticholic acid particles calculated to produce the desiredtherapeutic effect in association with the required pharmaceuticalcarrier. The specification for the dosage unit forms of the disclosureare dictated by and directly dependent on the unique characteristics ofthe obeticholic acid or obeticholic acid particles and the particulartherapeutic effect to be achieved.

In one embodiment of the present disclosure, there is provided apharmaceutical formulation comprising at least obeticholic acid asdescribed above in a formulation adapted for buccal and/or sublingual,or nasal administration. This embodiment provides administration ofobeticholic acid in a manner that avoids gastric complications, such asfirst pass metabolism by the gastric system and/or through the liver.This administration route may also reduce adsorption times, providingmore rapid onset of therapeutic benefit. The compounds of the presentdisclosure may provide particularly favorable solubility profiles tofacilitate sublingual/buccal formulations. Such formulations typicallyrequire relatively high concentrations of active ingredients to deliversufficient amounts of active ingredients to the limited surface area ofthe sublingual/buccal mucosa for the relatively short durations theformulation is in contact with the surface area, to allow the absorptionof the active ingredient. Thus, the very high activity of obeticholicacid, combined with its high solubility, facilitates its suitability forsublingual/buccal formulation.

Obeticholic acid is preferably formulated in a unit dosage form, eachdosage containing from about 0.05 mg to about 1500 mg. In anotherembodiment, the formulation comprises about 0.05 mg to about 100 mg. Inyet another embodiment, the formulation comprises about 1 mg to about100 mg. In another embodiment, the formulation comprises about 0.05 mgto about 50 mg. In yet another embodiment, the formulation comprisesabout 0.05 mg to about 30 mg. In another embodiment, the formulationcomprises about 0.05 mg to about 20 mg. In yet another embodiment, theformulation comprises about 0.5 mg to about 30 mg. In anotherembodiment, the formulation comprises about 0.5 mg to about 25 mg. Inyet another embodiment, the formulation comprises about 1 mg to about 25mg. In another embodiment, the formulation comprises about 4 mg to about26 mg. In another embodiment, the formulation comprises about 5 mg toabout 25 mg. In yet another embodiment, the formulation comprises about0.05 mg to about 2 mg. In another embodiment, the formulation comprisesabout 1 mg to about 2 mg. In one embodiment, the formulation comprisesabout 1.2 mg to about 1.8 mg. In one embodiment, the formulationcomprises about 1.3 mg to about 1.7 mg. In one embodiment, theformulation comprises about 1.5 mg. In one embodiment, the formulationcomprises about 0.05 mg to about 0.5 mg. In another embodiment, theformulation comprises about 0.08 mg to about 0.8 mg. In yet anotherembodiment, the formulation comprises about 0.1 mg to about 0.5 mg. Inanother embodiment, the formulation comprises about 0.25 mg.

Obeticholic acid is generally effective over a wide dosage range. Forexamples, dosages per day normally fall within the range of about 0.0001to about 30 mg/kg of body weight. In the treatment of adult humans, therange of about 0.1 to about 15 mg/kg/day, in single or divided dose, isespecially preferred. In one embodiment, the formulation comprises about0.05 mg to about 1500 mg. In another embodiment, the formulationcomprises about 0.05 mg to about 100 mg. In yet another embodiment, theformulation comprises about 1 mg to about 100 mg. In another embodiment,the formulation comprises about 0.05 mg to about 50 mg. In anotherembodiment, the formulation comprises about 0.05 mg to about 30 mg. Inyet another embodiment, the formulation comprises about 0.05 mg to about20 mg. In yet another embodiment, the formulation comprises about 0.05mg to about 10 mg.

In one embodiment, the formulation comprises about 3 mg to about 30 mg.In another embodiment, the formulation comprises about 0.05 mg to about25 mg. In another embodiment, the formulation comprises about 4 mg toabout 25 mg. In another embodiment, the formulation comprises about 5 mgto about 25 mg. In another embodiment, the formulation comprises about 5mg to about 10 mg. In one embodiment, the formulation comprises about 1mg to about 2 mg. In one embodiment, the formulation comprises about 1.2mg to about 1.8 mg. In one embodiment, the formulation comprises about1.3 mg to about 1.7 mg. In one embodiment, the formulation comprisesabout 0.05 mg to about 0.5 mg. In another embodiment, the formulationcomprises about 0.08 mg to about 0.8 mg. In yet another embodiment, theformulation comprises about 0.1 mg to about 0.5 mg. In anotherembodiment, the formulation comprises about 25 mg. In anotherembodiment, the formulation comprises about 10 mg. In one embodiment,the formulation comprises about 5 mg. In another embodiment, theformulation comprises about 0.25 mg. However, it will be understood thatthe amount of obeticholic acid actually administered will be determinedby a physician, in the light of the relevant circumstances, includingthe condition to be treated, the chosen route of administration, theform of obeticholic acid administered, the age, weight, and response ofthe individual patient, and the severity of the patient's symptoms, andtherefore the above dosage ranges are not intended to limit the scope ofthe disclosure in any way. In some instances dosage levels below thelower limit of the aforesaid range may be more than adequate, while inother cases still larger doses may be employed without causing anyharmful side effect, provided that such larger doses are first dividedinto several smaller doses for administration throughout the day.

The tablet of the present disclosure can comprise an intra-granularportion and an extra-granular portion. The intra-granular portion cancontain obeticholic acid, or a pharmaceutically acceptable salt, ester,or amino acid conjugate thereof, and one or more pharmaceuticalexcipients. The extra-granular portion can contain obeticholic acid, ora pharmaceutically acceptable salt, ester, or amino acid conjugatethereof, and one or more pharmaceutical excipients. In one embodiment,the intra-granular portion and the extra-granular portion of the tabletcontain obeticholic acid, or a pharmaceutically acceptable salt, ester,or amino acid conjugate thereof, and one or more pharmaceuticalexcipients. In another embodiment, the intra-granular portion containsobeticholic acid, or a pharmaceutically acceptable salt, ester, or aminoacid conjugate thereof and/or the extra-granular portion does notcontain obeticholic acid, or a pharmaceutically acceptable salt, ester,or amino acid conjugate thereof.

The presence of microcrystalline cellulose in the intra-granular portionand/or the extra-granular portion of a tablet comprising obeticholicacid or a pharmaceutically acceptable salt, ester, or amino acidconjugate thereof, can affect the properties of the tablet. In oneembodiment, when microcrystalline cellulose is added to only theintra-granular portion of the tablet, tablets of moderate hardness canbe produced. In another embodiment, when microcrystalline cellulose isadded to only the intra-granular portion of the tablet, tablets oftolerable hardness may be produced. In another embodiment, addition ofmicrocrystalline cellulose to both the intra-granular and extra-granularportions can provide tablets having superior tablet hardness and animproved dissolution profile. In one embodiment, microcrystallinecellulose is added to the intra-granular portion of the tablet. Inanother embodiment, microcrystalline cellulose is added to both theintra-granular portion and extra-granular portion of the tablet.

When the microcrystalline cellulose is present in the intra-granularportion it can be present in a ratio of microcrystalline cellulose toobeticholic acid, or a pharmaceutically acceptable salt, ester, or aminoacid conjugate thereof, between about 20:1 to about 1:5. In oneembodiment, the ratio of microcrystalline cellulose to obeticholic acid,or a pharmaceutically acceptable salt, ester, or amino acid conjugatethereof, may be, e.g., between about 19:1 to about 1:5, between about19:1 to about 1:4, between about 19:1 to about 1:3, between about 19:1to about 1:2, between about 18:1 to about 1:5, between about 18:1 toabout 1:4, between about 18:1 to about 1:3, between about 18:1 to about1:2, between about 17:1 to about 1:5, between about 17:1 to about 1:4,between about 17:1 to about 1:3, between about 17:1 to about 1:2,between about 16:1 to about 1:5, between about 16:1 to about 1:4,between about 16:1 to about 1:3, between about 16:1 to about 1:2,between about 15:1 to about 1:5, between about 15:1 to about 1:4,between about 15:1 to about 1:3, between about 15:1 to about 1:2,between about 14:1 to about 1:5, between about 14:1 to about 1:4,between about 14:1 to about 1:3, between about 14:1 to about 1:2,between about 13:1 to about 1:5, between about 13:1 to about 1:4,between about 13:1 to about 1:3, between about 13:1 to about 1:2,between about 12:1 to about 1:5, between about 12:1 to about 1:4,between about 12:1 to about 1:3, between about 12:1 to about 1:2,between about 11:1 to about 1:5, between about 11:1 to about 1:4,between about 11:1 to about 1:3, or between about 11:1 to about 1:2. Inanother embodiment, the ratio of microcrystalline cellulose toobeticholic acid, or a pharmaceutically acceptable salt, ester, or aminoacid conjugate thereof, is between about 10:1 to about 1:5, betweenabout 10:1 to about 1:4, between about 10:1 to about 1:3, or betweenabout 10:1 to about 1:2. In another embodiment, the ratio ofmicrocrystalline cellulose to obeticholic acid, or a pharmaceuticallyacceptable salt, ester, or amino acid conjugate thereof, is betweenabout 9:1 to about 1:4, between about 9:1 to about 1:3, between about9:1 to about 1:2, or between about 9:1 to about 1:1. In yet anotherembodiment, the ratio of microcrystalline cellulose to obeticholic acid,or a pharmaceutically acceptable salt, ester, or amino acid conjugatethereof, is between about 8:1 to about 1:3, between about 8:1 to about1:2, or between about 8:1 to about 1:1. In another embodiment, the ratioof microcrystalline cellulose to obeticholic acid, or a pharmaceuticallyacceptable salt, ester, or amino acid conjugate thereof, is betweenabout 7:1 to about 1:2 or between about 7:1 to about 1:1. In yet anotherembodiment, the ratio of microcrystalline cellulose to obeticholic acid,or a pharmaceutically acceptable salt, ester, or amino acid conjugatethereof, is between about 6:1 to about 1:1. In other embodiments, theratio of microcrystalline cellulose to obeticholic acid, or apharmaceutically acceptable salt, ester, or amino acid conjugatethereof, is between about 20:1 to about 1:1, between about 19:1 to about1:1, between about 18:1 to about 1:1, between about 17:1 to about 1:1,between about 16:1 to about 1:1, between about 15:1 to about 1:1,between about 14:1 to about 1:1, between about 13:1 to about 1:1,between about 12:1 to about 1:1, or between about 11:1 to about 1:1. Inanother embodiments, the ratio of microcrystalline cellulose toobeticholic acid, or a pharmaceutically acceptable salt, ester, or aminoacid conjugate thereof, is between about 20:1 to about 2:1, betweenabout 20:1 to about 3:1, between about 20:1 to about 4:1, between about20:1 to about 5:1, between about 20:1 to about 6:1, between about 20:1to about 7:1, between about 20:1 to about 8:1, between about 20:1 toabout 9:1, between about 20:1 to about 10:1, between about 20:1 to about11:1, between about 19:1 to about 2:1, between about 19:1 to about 3:1,between about 19:1 to about 4:1, between about 19:1 to about 5:1,between about 19:1 to about 6:1, between about 19:1 to about 7:1,between about 19:1 to about 8:1, between about 19:1 to about 9:1,between about 19:1 to about 10:1, between about 19:1 to about 11:1,between about 18:1 to about 2:1, between about 18:1 to about 3:1,between about 18:1 to about 4:1, between about 18:1 to about 5:1,between about 18:1 to about 6:1, between about 18:1 to about 7:1,between about 18:1 to about 8:1, between about 18:1 to about 9:1,between about 18:1 to about 10:1, between about 18:1 to about 11:1,between about 17:1 to about 2:1, between about 17:1 to about 3:1,between about 17:1 to about 4:1, between about 17:1 to about 5:1,between about 17:1 to about 6:1, between about 17:1 to about 7:1,between about 17:1 to about 8:1, between about 17:1 to about 9:1,between about 17:1 to about 10:1, between about 17:1 to about 11:1,between about 16:1 to about 2:1, between about 16:1 to about 3:1,between about 16:1 to about 4:1, between about 16:1 to about 5:1,between about 16:1 to about 6:1, between about 16:1 to about 7:1,between about 16:1 to about 8:1, between about 16:1 to about 9:1,between about 16:1 to about 10:1, between about 16:1 to about 11:1,between about 15:1 to about 2:1, between about 15:1 to about 3:1,between about 15:1 to about 4:1, between about 15:1 to about 5:1,between about 15:1 to about 6:1, between about 15:1 to about 7:1,between about 15:1 to about 8:1, between about 15:1 to about 9:1,between about 15:1 to about 10:1, between about 15:1 to about 11:1,between about 14:1 to about 2:1, between about 14:1 to about 3:1,between about 14:1 to about 4:1, between about 14:1 to about 5:1,between about 14:1 to about 6:1, between about 14:1 to about 7:1,between about 14:1 to about 8:1, between about 14:1 to about 9:1,between about 14:1 to about 10:1, between about 14:1 to about 11:1,between about 13:1 to about 2:1, between about 13:1 to about 3:1,between about 13:1 to about 4:1, between about 13:1 to about 5:1,between about 13:1 to about 6:1, between about 13:1 to about 7:1,between about 13:1 to about 8:1, between about 13:1 to about 9:1,between about 13:1 to about 10:1, between about 13:1 to about 11:1,between about 12:1 to about 2:1, between about 12:1 to about 3:1,between about 12:1 to about 4:1, between about 12:1 to about 5:1,between about 12:1 to about 6:1, between about 12:1 to about 7:1,between about 12:1 to about 8:1, between about 12:1 to about 9:1,between about 12:1 to about 10:1, between about 12:1 to about 11:1,between about 11:1 to about 2:1, between about 11:1 to about 3:1,between about 11:1 to about 4:1, between about 11:1 to about 5:1,between about 11:1 to about 6:1, between about 11:1 to about 7:1,between about 11:1 to about 8:1, or between about 11:1 to about 9:1, orbetween about 11:1 to about 10:1. Preferably, the ratio ofmicrocrystalline cellulose to obeticholic acid, or a pharmaceuticallyacceptable salt, ester, or amino acid conjugate thereof, may be betweenabout 20:1 to about 5:1, between about 16:1 to about 6:1, or betweenabout 16:1 to about 11:1, or any of the above-mentioned ratio rangesbetween about 20:1 to about 5:1. In another embodiment, the ratio ofmicrocrystalline cellulose to obeticholic acid, or a pharmaceuticallyacceptable salt, ester, or amino acid conjugate thereof, is about 16:1.In yet another embodiment, the ratio of microcrystalline cellulose toobeticholic acid, or a pharmaceutically acceptable salt, ester, or aminoacid conjugate thereof, is about 11:1. In another embodiment, the ratioof microcrystalline cellulose to obeticholic acid, or a pharmaceuticallyacceptable salt, ester, or amino acid conjugate thereof, is about 6:1.In yet another embodiment, the ratio of microcrystalline cellulose toobeticholic acid, or a pharmaceutically acceptable salt, ester, or aminoacid conjugate thereof, is between about 10:1 to about 1:1. In anotherembodiment, the ratio of microcrystalline cellulose to obeticholic acid,or a pharmaceutically acceptable salt, ester, or amino acid conjugatethereof, is between about 5:1 to about 1:1. In yet another embodiment,the ratio of microcrystalline cellulose to obeticholic acid, or apharmaceutically acceptable salt, ester, or amino acid conjugatethereof, is between about 3:1 to about 1:1. In another embodiment, theratio of microcrystalline cellulose to obeticholic acid, or apharmaceutically acceptable salt, ester, or amino acid conjugatethereof, is between about 2:1 to about 1:1. In another embodiment, theratio of microcrystalline cellulose to obeticholic acid, or apharmaceutically acceptable salt, ester, or amino acid conjugatethereof, is between about 4:1 to about 2:1. In yet another embodiment,the ratio of microcrystalline cellulose to obeticholic acid, or apharmaceutically acceptable salt, ester, or amino acid conjugatethereof, is between about 3:1 to about 2:1. In another embodiment, theratio of microcrystalline cellulose to obeticholic acid, or apharmaceutically acceptable salt, ester, or amino acid conjugatethereof, is about 4:1. In another embodiment, the ratio ofmicrocrystalline cellulose to obeticholic acid, or a pharmaceuticallyacceptable salt, ester, or amino acid conjugate thereof, is about 3:1.In yet another embodiment, the ratio of microcrystalline cellulose toobeticholic acid, or a pharmaceutically acceptable salt, ester, or aminoacid conjugate thereof, is about 2:1. In another embodiment, the ratioof microcrystalline cellulose to obeticholic acid, or a pharmaceuticallyacceptable salt, ester, or amino acid conjugate thereof, is about 1:1.

The tablet hardness of an obeticholic acid containing tablet can bebetween about 6 kilopascals (kP) to about 14 kP. In one embodiment, thetablet hardness is between about 7 kP to about 12 kP. In anotherembodiment, the tablet hardness is between about 8 kP to about 12 kP. Inyet another, the tablet hardness is between about 8 kP to about 11 kP.In another embodiment, the tablet hardness is between about 9 kP toabout 11 kP. In yet another embodiment, the tablet hardness is betweenabout 10 kP to about 11 kP.

In one embodiment, the tablets of the present disclosure comprisingobeticholic acid or a pharmaceutically acceptable salt, ester, or aminoacid conjugate thereof, microcrystalline cellulose and optionally one ormore additional pharmaceutical excipients in the intra-granular portion,and one or more pharmaceutical excipients in the extra-granular portionpossess increased hardness. In one embodiment, the tablets of thepresent disclosure comprising obeticholic acid or a pharmaceuticallyacceptable salt, ester, or amino acid conjugate thereof,microcrystalline cellulose and optionally one or more additionalpharmaceutical excipients in the intra-granular portion, andmicrocrystalline cellulose and optionally one or more additionalpharmaceutical excipients in the extra-granular portion possessincreased hardness. In particular, the tablets of the present disclosurecomprising microcrystalline cellulose in both the intra-granular portionand extra-granular portion possess increased hardness, for example, ascompared with tablets comprising microcrystalline cellulose in only theintra-granular portion. In one embodiment, the hardness is increased atleast about 5%, at least about 10%, at least about 20%, at least about30%, at least about 40%, at least about 50%, at least about 60%, or atleast about 70%, for example, as compared with tablets comprisingmicrocrystalline cellulose in only the intra-granular portion. In oneembodiment, the hardness is increased at least about 20%, at least about30%, at least about 40%, or at least about 50%, for example, as comparedwith tablets comprising microcrystalline cellulose in only theintra-granular portion. In another embodiment, the hardness is increasedbetween about 5% and about 45%, between about 10% and about 40%, betweenabout 15% and about 35%, between about 20% and about 30%, between about25% and about 35%, between about 25% and about 40%, between about 25%and about 50%, or between about 30% and about 50%, for example, ascompared with tablets comprising microcrystalline cellulose in only theintra-granular portion.

In one embodiment, the tablets of the present disclosure comprisingobeticholic acid or a pharmaceutically acceptable salt, ester, or aminoacid conjugate thereof, microcrystalline cellulose and optionally one ormore additional pharmaceutical excipients in the intra-granular portion,and one or more pharmaceutical excipients in the extra-granular portionpossess increased hardness. In another embodiment, the tablets of thepresent disclosure comprising obeticholic acid or a pharmaceuticallyacceptable salt, ester, or amino acid conjugate thereof,microcrystalline cellulose, and optionally one or more additionalpharmaceutical excipients in the intra-granular portion, andmicrocrystalline cellulose and optionally one or more additionalpharmaceutical excipients in the extra-granular portion possess improveddissolution of obeticholic acid or a pharmaceutically acceptable salt,ester, or amino acid conjugate thereof. In particular, the tablets ofthe present disclosure comprising microcrystalline cellulose in both theintra-granular portion and extra-granular portion possess improveddissolution of obeticholic acid or a pharmaceutically acceptable salt,ester, or amino acid conjugate thereof, for example, as compared withtablets comprising microcrystalline cellulose in only the intra-granularportion. For example, obeticholic acid or a pharmaceutically acceptablesalt, ester, or amino acid conjugate thereof in the tablets of thepresent disclosure dissolves (e.g., in a Disodium Hydrogen PhosphateBuffer) at a rate that is at least 2%, 3%, 4%, 5%, 6%, 7%, 8%, 9%, 10%,15%, 20%, 30%, 40%, 50%, 80%, or 100% faster than, for example, ascompared with the dissolution rate tablets comprising microcrystallinecellulose in only the intra-granular portion.

For example, about 55% to about 95% of obeticholic acid or apharmaceutically acceptable salt, ester, or amino acid conjugate thereofin the tablet of the present disclosure is dissolved within about 15minutes, or about 65% to about 95% is dissolved within about 30 minutes,or about 80% to about 95% is dissolved within about 45 minutes, or about87% to about 97% is dissolved within about 60 minutes, or about 87% toabout 99% is dissolved within about 75 minutes. For example, about 60%to about 84% of obeticholic acid or a pharmaceutically acceptable salt,ester, or amino acid conjugate thereof in the tablet of the presentdisclosure is dissolved within about 15 minutes, or about 75% to about91% is dissolved within about 30 minutes, or about 85% to about 93% isdissolved within about 45 minutes, or about 90% to about 96% isdissolved within about 60 minutes, or about 90% to about 97% isdissolved within about 75 minutes. For example, about 62% to about 83%of obeticholic acid or a pharmaceutically acceptable salt, ester, oramino acid conjugate thereof in the tablet of the present disclosure isdissolved within about 15 minutes, or about 80% to about 90% isdissolved within about 30 minutes, or about 87% to about 94% isdissolved within about 45 minutes, or about 92% to about 96% isdissolved within about 60 minutes, or about 91% to about 97% isdissolved within about 75 minutes. For example, about 60% to about 84%obeticholic acid or a pharmaceutically acceptable salt, ester, or aminoacid conjugate thereof in the tablet of the present disclosure isdissolved within about 15 minutes, or about 70% to about 90% isdissolved within about 30 minutes, or about 85% to about 92% isdissolved within about 45 minutes, or about 89% to about 96% isdissolved within about 60 minutes, or about 90% to about 96% isdissolved within about 75 minutes. For example, at least about 60%obeticholic acid or a pharmaceutically acceptable salt, ester, or aminoacid conjugate thereof in the tablet of the present disclosure isdissolved within about 15 minutes, or at least about 90% is dissolvedwithin about 60 minutes. For example, obeticholic acid or apharmaceutically acceptable salt, ester, or amino acid conjugate thereofin the tablet of the present disclosure has an in vitro dissolutionprofile of about 51% dissolved within about 15 minutes, or about 66%dissolved within about 30 minutes, or about 79% dissolved within about45 minutes, or about 85% dissolved within about 60 minutes.

Obeticholic acid tablets can be manufactured via a manufacturing processcomprising dry granulation by roller compaction followed by tabletcompression and coating. The process steps used to manufacture OCAtablets include: pre-blending, dry granulation, final blending,compression, coating, and packaging.

Obeticholic acid drug substance and one or more pharmaceuticalexcipients (i.e., microcrystalline cellulose, sodium starch glycolate,and/or magnesium stearate) are added and further optionally blended toproduce a premix. In one embodiment, OCA and microcrystalline celluloseis blended to produce a premix. In one embodiment, the premix isblended, passed through a screen and then again blended. In anotherembodiment, the one or more pharmaceutical excipients are added in smallportions and blended between each addition. In one embodiment, the oneor more pharmaceutical excipients are added sequentially. In anotherembodiment, the one or more pharmaceutical excipients are addedtogether.

The premix is then granulated and optionally milled to reduce particlesize. In one embodiment, the premix is roller compacted. In anotherembodiment, the premix is further milled. The premix can be milled usingvarious methods. In one embodiment, the premix is milled using a comil.In another embodiment, the premix is milled using a comil followed by anoscillating bar screen mill.

Once the premix is granulated, a final blending of the obeticholic acidtablet formulation is performed. In the final blending, one or morepharmaceutical excipients (i.e., microcrystalline cellulose, sodiumstarch glycolate, and/or magnesium stearate) are added to provide afinal blend which is further optionally blended. In one embodiment,microcrystalline cellulose is added during the final blending. In oneembodiment, the one or more pharmaceutical excipients are addedsequentially. In another embodiment, the one or more pharmaceuticalexcipients are added together.

The final blend is then compressed to form the tablet. The compressionparameters can be adjusted to produce tablets of the desired weight,hardness, thickness, and friability. The tablet press speed and feederspeed can also be adjusted to help reduce tablet weight variation. Theobeticholic acid tablets are then coated with a coating material (i.e.,Opadry® II white, Opadry® II green, or Opadry® II yellow) using acoating solution.

Obeticholic acid compositions described herein can be administered inaccordance with a dosing regimen. A dosing regimen refers to continualand intermittent administration of a obeticholic acid compositiondescribed herein at one or more of the amounts described herein. Thus,in certain instances, a dosing regimen can include administration of aobeticholic acid composition described herein continually for any numberof days, weeks, months, or years as set forth herein. In otherinstances, a dosing regimen can include administration of a obeticholicacid composition described herein intermittently, where, for example,the composition is administered for one period of time followed by arest period or off period where the obeticholic acid composition is notadministered.

Obeticholic acid compositions useful in the methods of treatingdescribed herein include administration of such compositions daily (QD),every other day (Q2D), once a week (QW), twice a week (BID), three timesa week (TIW), once a month (QM), or twice a month (Q2M). In oneembodiment, a obeticholic acid composition described herein isadministered QD. Thus, an effective amount of an obeticholic acidcomposition described herein can be administered QD to treat a diseaseor condition described herein. A starting dose described herein can beadministered QD during the course of a titration period described hereinto treat a disease or condition described herein. An adjusted dosedescribed herein can be administered QD to treat a disease or conditiondescribed herein.

In another embodiment, an obeticholic acid composition described hereinis administered Q2D. An effective amount of an obeticholic acidcomposition described herein can be administered Q2D to treat a diseaseor condition described herein. A starting dose described herein can beadministered Q2D during the course of a titration period describedherein to treat a disease or condition described herein. An adjusteddose described herein can be administered Q2D to treat a disease orcondition described herein.

In another embodiment, an obeticholic acid composition is describedherein administered QW. An effective amount of an obeticholic acidcomposition described herein can be administered QW to treat a diseaseor condition described herein. A starting dose described herein can beadministered QW during the course of a titration period described hereinto treat a disease or condition described herein. An adjusted dosedescribed herein can be administered QW to treat a disease or conditiondescribed herein.

In another embodiment, an obeticholic acid composition is describedherein administered BID. An effective amount of an obeticholic acidcomposition described herein can be administered BID to treat a diseaseor condition described herein. A starting dose described herein can beadministered BID during the course of a titration period describedherein to treat a disease or condition described herein. An adjusteddose described herein can be administered BID to treat a disease orcondition described herein.

In another embodiment, an obeticholic acid composition is describedherein administered TIW. An effective amount of an obeticholic acidcomposition described herein can be administered TIW to treat a diseaseor condition described herein. A starting dose described herein can beadministered TIW during the course of a titration period describedherein to treat a disease or condition described herein. An adjusteddose described herein can be administered TIW to treat a disease orcondition described herein.

In another embodiment, an obeticholic acid composition is describedherein administered QM. An effective amount of an obeticholic acidcomposition described herein can be administered QM to treat a diseaseor condition described herein. A starting dose described herein can beadministered QM during the course of a titration period described hereinto treat a disease or condition described herein. An adjusted dosedescribed herein can be administered QM to treat a disease or conditiondescribed herein.

In another embodiment, an obeticholic acid composition is describedherein administered Q2M. An effective amount of an obeticholic acidcomposition described herein can be administered Q2M to treat a diseaseor condition described herein. A starting dose described herein can beadministered Q2M during the course of a titration period describedherein to treat a disease or condition described herein. An adjusteddose described herein can be administered Q2M to treat a disease orcondition described herein.

The embodiments described above include administration at an amountdescribed above. For example, an obeticholic acid composition describedherein can be administered in a frequency provided above in an amount of5 mg, 10 mg, 25 mg, or 50 mg.

Dosing regimens of the obeticholic acid compositions described hereinuseful for treating diseases and conditions described herein can includea titration period. A titration period typically includes a lower dosageof an obeticholic acid composition described herein for a period oftime. In certain instances, and without being bound by any particulartheory, administration using a titration period described herein candecrease or eliminate the onset of adverse effects. In other instances,and without being bound by any particular theory, administration using atitration period described herein can permit increased dosages ofobeticholic acid compositions described herein to an individual over thecourse of a treatment.

A titration period can be a period of time of about: 1 month to about 24months; 1 month to about 21 months; 1 month to about 18 months; 1 monthto about 15 months; 1 month to about 12 months; 1 month to about 9months; 1 month to about 6 months; or 1 month to about 3 months. Inanother embodiment, a titration period includes a time of about: 3months to about 24 months; 3 months to about 21 months; 3 months toabout 18 months; 3 months to about 15 months; 3 months to about 12months; 3 or months to about 6 months. In still another embodiment, atitration period includes a time of about: 6 months to about 24 months;6 months to about 21 months; 6 months to about 18 months; 6 months toabout 15 months; or 6 months to about 12 months. In yet anotherembodiment, a titration period includes a time of about: 2 months toabout 4 months; 2 months to about 7 months; 2 months to about 8 months;4 months to about 8 months; 5 months to about 7 months; or 5 months toabout 8 months. For example, a titration period can be about 1 to about6 months. In another example, a titration period can be about 3 to about6 months.

A titration period can include a time of about 1, 2, 3, 4, 5, 6, 7, 8,9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, or 24 months.In certain embodiments, a titration period includes a time of about 1,2, 3, 4, 5, 6, 7, 8, 9, 10, 11, or 12 months. In another embodiment, thetitration period includes a time of about 1, 2, 3, 4, 5, 6, 7, 8, or 9months. In another embodiment, the titration period includes a time ofabout 1, 2, 3, 4, 5, or 6 months. In another embodiment, the titrationperiod includes a time of about 1, 2, or 3 months. For example, atitration period can be about 1 month. In another example a titrationperiod can be about 2 months. In another example a titration period canbe about 3 months. In still another example a titration period can beabout 4 months. In yet another example a titration period can be about 5months. In another example a titration period can be about 6 months. Inone example a titration period is 3 months or 6 months. In anotherexample a titration period can be about 7 months. In another example atitration period can be about 8 months. In another example a titrationperiod can be about 9 months.

As provided above, the amounts of a obeticholic acid compositiondescribed herein, optionally administered in a titration period can bereduced compared to an adjusted amount as described herein. Accordingly,provided herein are treatment regimens that include administeringobeticholic acid compositions described herein for the treatment of adisease or condition described herein (e.g., PBC) wherein the startingdose administered during a titration period described above is lowerthan the amount of an adjusted dose administered after a titrationperiod. Still further provided herein are treatment regimens thatinclude administering obeticholic acid compositions described herein forthe treatment of a disease or condition described herein (e.g., PBC)where the starting dose administered during a titration period describedabove is lower than the amount of an adjusted dose administered after atitration period and where the frequency of administration (e.g., QD,Q2D, or QW) for the adjusted dose is greater than the frequency ofadministration of the starting dose. Still further provided herein aretreatment regimens that include administering obeticholic acidcompositions described herein for the treatment of a disease orcondition described herein (e.g., PBC) where the starting doseadministered during a titration period described above is lower than theamount of an adjusted dose administered after a titration period andwhere the frequency of administration (e.g., QD, Q2D, or QW) for theadjusted dose is less than the frequency of administration of thestarting dose. Increases in the adjusted dose (or any re-adjusted dose)can be performed after the patient's liver function is assessed,monitored, or measured as described herein, where the liver function isconsidered not-impaired.

In embodiments, the adjusted dose can be increased compared to thestarting dose when the level of ALP is about equal to or is not reducedcompared to a control as described herein. In embodiments, the adjustedcan be increased compared to the starting dose when the level ofbilirubin is about equal to or is not reduced compared to a control asdescribed herein. In embodiments, the adjusted dose can be increasedcompared to the starting dose when the level of ALP and bilirubin areabout equal to or are not reduced compared to a control as describedherein. In certain instances, the adjusted dose can be increasedcompared to the starting dose where a patient described herein toleratesthe starting dose amount. In certain embodiments, the starting dose canbe 5 mg. In certain embodiments, the starting dose is 10 mg. In certainembodiments, the starting dose is 5 mg and the adjusted dose is greaterthan 5 mg (e.g., about 6 mg to about 50 mg). In one embodiment, thestarting dose is 5 mg and the adjusted dose is 10 mg.

Also provided herein are treatment regimens that include administeringobeticholic acid compositions described herein for the treatment of adisease or condition described herein (e.g., PBC) where the startingdose administered during a titration period described above is equal tothe amount of an adjusted dose administered after a titration period.Further provided herein are treatment regimens that includeadministering obeticholic acid compositions described herein for thetreatment of a disease or condition described herein (e.g., PBC) wherethe starting dose administered during a titration period described aboveis equal to the amount of an adjusted dose administered after atitration period and where the frequency of administration (e.g., QD,Q2D, or QW) for the starting dose is the same as the adjusted dose.Still further provided herein are treatment regimens that includeadministering obeticholic acid compositions described herein for thetreatment of a disease or condition described herein (e.g. PBC) wherethe starting dose administered during a titration period described aboveis equal to the amount of an adjusted dose administered after atitration period and where the frequency of administration (e.g., QD,Q2D, or QW) for the adjusted dose is greater than the frequency ofadministration of the starting dose. Still further provided herein aretreatment regimens that include administering obeticholic acidcompositions described herein for the treatment of a disease orcondition described herein (e.g., PBC) where the starting doseadministered during a titration period described above is equal to theamount of an adjusted dose administered after a titration period andwhere the frequency of administration (e.g., QD, Q2D, or QW) for theadjusted dose is less than the frequency of administration of thestarting dose. The adjusted dose (or any re-adjusted dose) can be equalto the starting dose where the patient's liver function is assessed,monitored, or measured as described herein, where the liver function isconsidered not-impaired.

In embodiments, the adjusted dose can be equal to the starting dose whenthe level of ALP is reduced compared to a control as described herein.In embodiments, the adjusted dose can be equal to the starting dose whenthe level of bilirubin is reduced compared to a control as describedherein. In embodiments, the adjusted dose can be equal to the startingdose when the level of ALP and bilirubin are reduced compared to acontrol as described herein. In certain instances, the adjusted dose canbe equal to the starting dose where a patient described herein toleratesor poorly tolerates (e.g., has onset of adverse effects describedherein) the starting dose amount. In certain embodiments, the startingdose can be 5 mg. In certain embodiments, the starting dose is 10 mg. Incertain embodiments, the starting dose is 5 mg and the adjusted dose is5 mg. In one embodiment, the starting dose is 10 mg and the adjusteddose is 10 mg.

Further provided herein are treatment regimens that optionally include astarting dose and an adjusted dose as provided in the regimens above,where the adjusted dose is further reduced during the course oftreatment. In certain instances, the adjusted dose is reduced to a newre-adjusted dose having a decreased amount of an obeticholic acidcomposition described herein. In other instances the adjusted dose isreduced to a new re-adjusted dose having the same amount of anobeticholic acid composition described herein but a decreased frequencyof administration (e.g., from QD to Q2D or QW). In still otherinstances, the adjusted dose is modified such that the re-adjusted doseincludes a decreased amount of an obeticholic acid composition describedherein and is administered at a decreased frequency compared to theadjusted dose.

The obeticholic acid composition described herein can be administeredfor any number of days, weeks, months, or years, including indefinitely,provided that the dosage remains efficacious for the patient and thepatient tolerates the dosage (e.g., an adjusted or re-adjusted dose asdescribed herein). In certain instances, an obeticholic acid compositiondescribed herein is administered to a patient described herein untilloss of efficacy, or until development of unacceptable toxicity orundesired adverse effects, such as, for example, those described herein.Daily dosing of an obeticholic acid composition described herein can bedependent upon patient tolerance to the dosage, composition, orfrequency of administration. For example, daily dosing can beadministered to a patient described herein where the patient tolerates adaily dosage amount (e.g., 5 mg, 10 mg, 25 mg, or 50 mg). Alternativelyor additionally, the daily dosing can be modified to increase or reducethe amount of an obeticholic acid composition described herein asprovided above where the patient is tolerant or is intolerant to thedose, respectively. In certain embodiments, modification of the adjusteddose (or any re-adjusted dose) can be performed after the patient'sliver function is assessed, monitored, or measured as described herein.In certain instances, the adjusted dose (or re-adjusted dose) isincreased or maintained (e.g., equivalent to a starting dose) where theliver function is not-impaired. In other instances, the adjusted dose(or re-adjusted dose) is decreased or maintained (e.g., equivalent to astarting dose) where the patient's liver function is impaired.

The amount of an obeticholic acid described herein administered to apatient described herein can be modified as a result of intolerabilityor development of one or more adverse effects such as those describedherein. For example, in one instance the amount of an obeticholic acidcomposition described herein administered to a patient can be changedfrom a QD dosage to a Q2D dosage. In certain embodiments, the dosage ofan obeticholic acid described herein is modified from a QD to Q2D dosageupon development of an adverse effect described herein (e.g., severepruritus). In one example, administration of an obeticholic acidcomposition described herein at 5 mg QD can be modified to a 5 mg Q2Ddosage. Such a modification can reduce or eliminate undesired adverseeffects while maintaining the desired efficacy. In another example,administration of an obeticholic acid composition described herein at 10mg QD can be reduced to 5 mg QD. It should be understood that exemplarydosing regimens described herein can be combined. For example, a reduceddosage of an obeticholic acid composition described herein from 10 mg to5 mg QD could be further reduced to a 5 mg Q2D dosage where undesiredadverse effects remain. In still another example, dosing of theobeticholic acid composition can be temporarily suspended (e.g., an offperiod) for about 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, or 14 days,or 1, 2, 3, or 4 weeks.

In one exemplary dosing regimen, a PBC patient is administered anobeticholic acid composition described herein where: the starting doseof the obeticholic acid composition described herein is administered QDto a patient described herein at an amount of 5 mg and the obeticholicacid composition is administered QD to the patient in an adjusted doseof 5 mg. The exemplary dosing regimen can include a titration period ofabout 1 to about 6 months.

In another exemplary dosing regimen, a PBC patient is administered anobeticholic acid composition described herein where: the starting doseof the obeticholic acid composition described herein is administered QDto a patient described herein at an amount of 5 mg in a titration periodof about 3 months or about 6 months and the obeticholic acid compositionis administered QD to the patient in an adjusted dose of 5 mg.

In still another exemplary dosing regimen, a PBC patient is administeredan obeticholic acid composition described herein where: the startingdose of the obeticholic acid composition described herein isadministered QD to a patient in a titration period of about 3 months orabout 6 months and the obeticholic acid composition is administered QDto the patient in an adjusted dose of 10 mg.

In another exemplary dosing regimen, a PBC patient is administered anobeticholic acid composition described herein where: the starting doseof the obeticholic acid composition described herein is administered QDto a patient in a titration period of about 3 months or about 6 monthsand the obeticholic acid composition is administered QD to the patientin an adjusted dose of 5 mg, where the adjusted dose is modified to a 5mg Q2D re-adjusted dose upon development of an adverse effect (e.g.,pruritus or severe pruritus).

In still another exemplary dosing regimen, a PBC patient is administereda obeticholic acid composition described herein, where the starting doseof the obeticholic acid composition described herein is administered QDto a patient in a titration period of about 3 months or about 6 monthsand the obeticholic acid composition is administered QD to the patientin an adjusted dose of 10 mg, where the adjusted dose is subsequentlymodified to a 5 mg QD re-adjusted dose upon development of an adverseeffect (e.g., pruritus or severe pruritus).

The amount of an obeticholic acid composition described hereinadministered to a patient can be determined by the existence of anypreexisting conditions in the patient. For example, where a patientdescribed herein has or has had hepatic impairment, the dosage of theobeticholic acid composition described herein can be modified. Incertain instances, the hepatic impairment is a Child-Pugh Class B orClass C hepatic impairment. In one embodiment, the hepatic impairment isChild-Pugh Class C. In such instances, the amount of an obeticholic acidcomposition described herein can be administered in a decreased amountduring and after a titration period when compared to administration ofthe same obeticholic acid composition to a patient who does not havehepatic impairment.

In one example dosing regimen, a patient having hepatic impairment isadministered an obeticholic acid composition described herein at anamount of about 1 mg to about 5 mg, where the composition isadministered at least once weekly (QW). In one instance, the obeticholicacid composition described herein is administered at an amount of about5 mg once weekly to a patient diagnosed with hepatic impairment (e.g.,Child-Pugh Class B or C).

For example, the dosing regimen can include administering an obeticholicacid composition described herein to a patient having hepaticimpairment, where the obeticholic acid composition is administered at astarting dose of 5 mg QW for a titration period of 3 or 6 months andadministered at an adjusted dose of 5 mg QW. The patient's liverfunction can be assessed, monitored, or measured as described herein.Where the patient's liver function is not impaired, the adjusted dosecan be increased to a re-adjusted dose of 5 mg administered BIW or 5 mgQD.

In certain instances a patient can develop liver impairment during thecourse of administration. It is understood, using the disclosureprovided herein, that the adjusted dose can be decreased in amount orfrequency to avoid progression of liver impairment.

Further provided herein is a method of treating PBC in a patient in needthereof by administering an effective amount of a obeticholic acidcomposition described herein QD, where the effective amount is either a5 mg or 10 mg dose. In another aspect is a method of treating PBC in apatient in need thereof by administering a starting dose of 5 mg QD ofan obeticholic acid composition described herein for at least 3 months;evaluating the tolerance of the patient, the patient's liver function asdescribed herein, and/or the efficacy of treatment, where patienttolerance, liver function, and/or lowered efficacy indicate end of atitration period and administration of an adjusted dose of 10 mg QD. Inone embodiment, the patient tolerance, liver function, and/or loweredefficacy indicate end of a titration period and administration of anadjusted dose of 5 mg QD.

In embodiments described herein, an obeticholic acid compositiondescribed herein can be metabolized to a obeticholic acid conjugate,such as for example, a glycine, taurine, or sarcosine conjugate ofobeticholic acid. Such metabolites can be useful in treating a diseaseor condition provided herein. In certain instances, production ofconjugates can be assessed, monitored, measured, or detected, asdescribed herein during the course of a treatment. In some embodiments,increased levels of obeticholic acid conjugates can result in adjusteddosages of an obeticholic acid composition described herein.

Also provided herein are methods of treating a disease or conditiondescribed herein where the treatment further includes administration ofone or more active agents and combinations thereof. For example,ursodeoxycholic acid (UDCA) is commonly administered for treatment ofPBC, yet a majority of patients administered UDCA alone have either aninadequate response or no response to the treatment. In such instances,there is a need for new medicaments or additional medicaments for thetreatment of PBC. The obeticholic acid compositions described herein canbe administered as described herein (e.g., according to one or moredosing regimens provided above) in combination with UDCA. In someinstances, the UDCA is administered at an amount of about 10 to 15mg/kg/day. In another instance, the UDCA is administered at an amount ofabout 300, 600, 900, or 1200 mg/day. Administration of UDCA can includea rest or off period of 1, 2, 3, or 4 weeks. In one example, anobeticholic acid composition described herein is administered asdescribed herein in combination with UDCA, where the UDCA isadministered at an amount provided above or in accordance with a packageinsert. The term package insert refers to instructions customarilyincluded in commercial packages of medicaments approved by the FDA or asimilar regulatory agency of a country other than the USA, whichcontains information about, for example, the usage, dosage,administration, contraindications, and/or warnings concerning the use ofsuch medicaments.

In another example, the active agent is a peroxisomeproliferator-activated receptor alpha (PPARα) agonist, a peroxisomeproliferator-activated receptor delta (PPARδ) agonist, a dual PPARα/δagonist, a dual PPARα/γ agonist, or pan-PPAR agonist, an HMG CoAreductase inhibitor, a GLP1 agonist, insulin, insulin mimetic,metformin, a GTP4 agonist, an HST2 inhibitor, a DPP-IV inhibitor, anSGLT2 inhibitor or a hydroxysteroid dehydrogenase (HSD) inhibitor, suchas an 11β-HSD1 inhibitor, an ASK1 inhibitor, an ACC1 inhibitor, a NOX1and/or NOX4 inhibitor, an inhibitor or antagonist of one or morechemokine receptors, such as, for example, CCR2 and CCR5.

In instances where an obeticholic acid composition described herein isuseful for the treatment of a cancer described herein, such compositionscan be co-administered with one or more cancer agents.

The anti-cancer agent useful in methods of treating solid-tumor cancersprovided herein can include any known class of anti-cancer agents suchas, for example, radiation therapy, operations, alkylating agents,antimetabolites, anthracyclines, campothecins, vinca alkaloids, taxanesor platinums, as well as other antineoplastic agents known in the art.Such anti-cancer agent and antineoplastic agent classifications areknown in the art and used in accordance with their plain and ordinarymeaning.

Exemplary anti-cancer agents include but are not limited to: ABRAXANE;abiraterone; ace-11; aclarubicin; acivicin; acodazole hydrochloride;acronine; actinomycin; acylfulvene; adecypenol; adozelesin; adriamycin;aldesleukin; all trans-retinoic acid (ATRA); altretamine; ambamustine;ambomycin; ametantrone acetate; amidox; amifostine; aminoglutethimide;aminolevulinic acid; amrubicin; amsacrine; anagrelide; anastrozole;andrographolide; antarelix; anthramycin; aphidicolin glycinate; apurinicacid; ara-CDP-DL-PTBA; arginine deaminase; ARRY-162; ARRY-300;ARRY-142266; AS703026; asparaginase; asperlin; asulacrine; atamestane;atrimustine; AVASTIN; axinastatin 1; axinastatin 2; axinastatin 3;azasetron; azatoxin; azatyrosine; azacitidine; AZD8330; azetepa;azotomycin; balanol; batimastat; BAY 11-7082; BAY 43-9006; BAY 869766;bendamustine; benzochlorins; benzodepa; benzoylstaurosporine;beta-alethine; betaclamycin B; betulinic acid; b-FGF inhibitor;bicalutamide; bisantrene; bisaziridinylspermine; bisnafide; bisnafidedimesylate; bistratene A; bisantrene hydrochloride; bleomycin; bleomycinsulfate; busulfan; bizelesin; breflate; bortezomib; brequinar sodium;bropirimine; budotitane; buthionine sulfoximine; bryostatin;cactinomycin; calusterone; calcipotriol; calphostin C; camptothecinderivatives; capecitabine; carboxamide-amino-triazole;carboxyamidotriazole; CaRest M3; CARN 700; caracemide; carbetimer;carboplatin; carmustine; carubicin hydrochloride; carzelesin;castanospermine; cecropin B; cedefingol; celecoxib; cetrorelix;chlorins; chloroquinoxaline sulfonamide; cicaprost; chlorambucil;Chlorofusin; cirolemycin; cisplatin; CI-1040; cis-porphyrin; cladribine;clomifene analogues; clotrimazole; collismycin A; collismycin B;combretastatin A4; combretastatin analogue; conagenin; crambescidin 816;crisnatol; crisnatol mesylate; cryptophycin 8; cryptophycin Aderivatives; curacin A; cyclopentanthraquinones; cycloplatam; cypemycin;cyclophosphamide; cytarabine; cytarabine ocfosfate; cytolytic factor;cytostatin; dacarbazine; dactinomycin; daunorubicin; daunorubicinhydrochloride; decarbazine; dacliximab; dasatinib; decitabine;dehydrodidemnin B; deslorelin; dexamethasone; dexifosfamide;dexrazoxane; dexverapamil; dexormaplatin; dezaguanine; dezaguaninemesylate; diaziquone; didemnin B; didox; diethylnorspermine; dihydro 5azacytidine; dihydrotaxol; 9-dioxamycin; diphenyl spiromustine;docosanol; dolasetron; docetaxel; doxorubicin; doxorubicinhydrochloride; doxifluridine; droloxifene; droloxifene citrate;dromostanolone propionate; dronabinol; duazomycin; duocarmycin SA;ebselen; ecomustine; edelfosine; edrecolomab; edatrexate; eflornithinehydrochloride; eflornithine; elemene; emitefur; elsamitrucin;enloplatin; enpromate; epipropidine; epirubicin; epirubicinhydrochloride; epristeride; erbulozole; eribulin; esorubicinhydrochloride; estramustine; estramustine phosphate sodium; etanidazole;etoposide; etoposide phosphate; etoprine; exemestane; fadrozole;fadrozole hydrochloride; fazarabine; fenretinide; filgrastim;finasteride; flavopiridol; flezelastine; fluasterone; floxuridine;fludarabine phosphate; fludarabine; fluorodaunorubicin hydrochloride;forfenimex; formestane; fluorouracil; floxouridine; flurocitabine;fosquidone; fostriecin sodium; fostriecin; fotemustine; gadoliniumtexaphyrin; gallium nitrate; galocitabine; ganirelix; gelatinaseinhibitors; gemcitabine; geldanamycin; gossyphol; GDC-0973;GSK1120212/trametinib; herceptin; hydroxyurea; hepsulfam; heregulin;hexamethylene bisacetamide; hypericin; ibandronic acid; ibrutinib;idarubicin; idarubicin hydrochloride; ifosfamide; canfosfamide;ilmofosine; iproplatin; idoxifene; idramantone; ilmofosine; ilomastat;imidazoacridones; imatinib (e.g., GLEEVEC); imiquimod; iniparib (BSI201); iobenguane; iododoxorubicin; ipomeanol; irinotecan; irinotecanhydrochloride; irsogladine; isobengazole; isohomohalicondrin B;itasetron; iimofosine; interleukin IL-2 (including recombinantinterleukin II; or rlL.sub.2); interferon alfa-2a; interferon alfa-2b;interferon alfa-n1; interferon alfa-n3; interferon beta-1a; interferongamma-1b; jasplakinolide; kahalalide F; lamellarin N triacetate;lanreotide; leinamycin; lenograstim; lentinan sulfate; leptolstatin;letrozole; leuprorelin; levamisole; lenalidomide; lenvatinib; liarozole;lissoclinamide 7; lobaplatin; lombricine; lometrexol; lonidamine;losoxantrone; lovastatin; loxoribine; lurtotecan; lutetium texaphyrin;lysofylline; lanreotide acetate; lapatinib; letrozole; leucovorin;leuprolide acetate; liarozole hydrochloride; lometrexol sodium;lomustine; losoxantrone hydrochloride; pomalidomide; LY294002;maitansine; mannostatin A; marimastat; masoprocol; maspin; matrilysininhibitors; menogaril; merbarone; meterelin; methioninase;metoclopramide; MIF inhibitor; mifepristone; miltefosine; mirimostim;mitoguazone; mitolactol; mitonafide; mitoxantrone; mofarotene;molgramostim; mopidamol; mycaperoxide B; myriaporone; maytansine;mechlorethamine hydrochloride; megestrol acetate; melengestrol acetate;melphalan; mercaptopurine; methotrexate; methotrexate sodium; metoprine;meturedepa; mitindomide; mitocarcin; mitocromin; mitogillin; mitomalcin;mitomycin; mitosper; mitotane; mitoxantrone hydrochloride; mycophenolicacid; nafarelin; nagrestip; napavin; naphterpin; nartograstim;nedaplatin; nemorubicin; neridronic acid; nilutamide; nisamycin; nitricoxide modulators; nitroxide antioxidant; nitrullyn; nocodazole;nogalamycin; oblimersen (GENASENSE); octreotide; okicenone; olaparib(LYNPARZA); oligonucleotides; onapristone; ondansetron; oracin; oralcytokine inducer; ormaplatin; oxisuran; oxaloplatin; osaterone;oxaliplatin; oxaunomycin; palauamine; palmitoylrhizoxin; pamidronicacid; panaxytriol; panomifene; parabactin; PARP (polyADP ribosepolymerase) inhibitors; pazelliptine; pegaspargase; peldesine; pentosanpolysulfate sodium; pentostatin; pentrozole; perflubron; perfosfamide;perillyl alcohol; phenazinomycin; phenylacetate; phosphatase inhibitors;picibanil; pilocarpine hydrochloride; pirarubicin; piritrexim; placetinA; placetin B; porfiromycin; prednisone; prostaglandin J2;pyrazoloacridine; paclitaxel; PD035901; PD184352; PD318026; PD98059;peliomycin; pentamustine; peplomycin sulfate; PKC412; pipobroman;piposulfan; piroxantrone hydrochloride; plicamycin; plomestane;podophyllotoxin; polyphenol E; porfimer sodium; porfiromycin;prednimustine; procarbazine; procarbazine hydrochloride; puromycin;puromycin hydrochloride; pyrazofurin; raltitrexed; ramosetron;retelliptine demethylated; rhizoxin; rituximab; Ru retinamide;rogletimide; rohitukine; romurtide; roquinimex; rubiginone B1; ruboxyl;riboprine; romidepsin; rucaparib; safingol; safingol hydrochloride;saintopin; sarcophytol A; sargramostim; semustine; sizofiran;sobuzoxane; sodium borocaptate; sodium phenylacetate; solverol;sonermin; sorafenib; sunitinib; sparfosic acid; spicamycin D;spiromustine; splenopentin; spongistatin 1; Spongistatin 2; Spongistatin3; Spongistatin 4; Spongistatin 5; Spongistatin 6; Spongistatin 7;Spongistatin 8; and Spongistatin 9; squalamine; stipiamide; stromelysininhibitors; sulfinosine; suradista; suramin; swainsonine; SB239063;selumetinib/AZD6244; simtrazene; SP600125; sparfosate sodium;sparsomycin; spirogermanium hydrochloride; spiroplatin; streptonigrin;streptozocin; sulofenur; tallimustine; tamoxifen methiodide; talazoparib(BMN 673); tauromustine; tazarotene; tecogalan sodium; tegafur;tellurapyrylium; temoporfin; temozolomide; teniposide;tetrachlorodecaoxide; tetrazomine; thaliblastine; thiocoraline;thrombopoietin; thymalfasin; thymopoietin receptor agonist; thymotrinan;tirapazamine; titanocene bichloride; topsentin; toremifene; tretinoin;triacetyluridine; triciribine; trimetrexate; triptorelin; tropisetron;turosteride; tyrphostins; talisomycin; TAK-733; taxotere; tegafur;teloxantrone hydrochloride; teroxirone; testolactone; thiamiprine;thioguanine; thiotepa; tiazofurin; tirapazamine; toremifene citrate;trastuzumab; trestolone acetate; triciribine phosphate; trimetrexate;trimetrexate glucuronate; triptorelin; tubulozole hydrochloride; tumornecrosis factor-related apoptosis-inducing ligand (TRAIL); UBCinhibitors; ubenimex; U0126; uracil mustard; uredepa; vapreotide;variolin B; velaresol; veliparib (ABT-888); veramine; verteporfin;vinorelbine; vinxaltine; vitaxin; vinblastine; vinblastine sulfate;vincristine sulfate; vindesine; vindesine sulfate; vinepidine sulfate;vinglycinate sulfate; vinleurosine sulfate; vinorelbine tartrate;vinrosidine sulfate; vinzolidine sulfate; vorozole; wortmannin; XL518;zanoterone; zeniplatin; zilascorb; zinostatin stimalamer; zinostatin;and zorubicin hydrochloride.

Other exemplary anti-cancer agents include Erbulozole (e.g., R-55104);Dolastatin 10 (e.g., DLS-10 and NSC-376128); Mivobulin isethionate(e.g., CI-980); NSC-639829; Discodermolide (e.g., NVP-XX-A-296); ABT-751(Abbott; e.g., E-7010); Altorhyrtin A; Altorhyrtin C; Cemadotinhydrochloride (e.g., LU-103793 and NSC-D-669356); CEP 9722; EpothiloneA; Epothilone B; Epothilone C; Epothilone D; Epothilone E; Epothilone F;Epothilone B N-oxide; Epothilone AN-oxide; 16-aza-epothilone B;21-aminoepothilone B; 21-hydroxyepothilone D; 26-fluoroepothilone;Auristatin PE (e.g., NSC-654663); Soblidotin (e.g., TZT-1027); LS-4559-P(Pharmacia; e.g., LS-4577); LS-4578 (Pharmacia; e.g., LS-477-P); LS-4477(Pharmacia); LS-4559 (Pharmacia); RPR-112378 (Aventis); DZ-3358(Daiichi); FR-182877 (Fujisawa; e.g., WS-9265B); GS-164 (Takeda); GS-198(Takeda); KAR-2 (Hungarian Academy of Sciences); BSF-223651 (BASF; e.g.,ILX-651 and LU-223651); SAH-49960 (Lilly/Novartis); SDZ-268970(Lilly/Novartis); AM-97 (Armad/Kyowa Hakko); AM-132 (Armad); AM-138(Armad/Kyowa Hakko); IDN-5005 (Indena); Cryptophycin 52 (e.g.,LY-355703); AC-7739 (Ajinomoto; e.g., AVE-8063A and CS-39.HCl); AC-7700(Ajinomoto; e.g., AVE-8062; AVE-8062A; CS-39-L-Ser.HCl; andRPR-258062A); Vitilevuamide; Tubulysin A; Canadensol; CA-170 (Curis,Inc.); Centaureidin (e.g., NSC-106969); T-138067 (Tularik; e.g., T-67;TL-138067 and TI-138067); COBRA-1 (Parker Hughes Institute; e.g.,DDE-261 and WHI-261); H10 (Kansas State University); H16 (Kansas StateUniversity); Oncocidin A1 (e.g., BTO-956 and DIME); DDE-313 (ParkerHughes Institute); Fijianolide B; Laulimalide; SPA-2 (Parker HughesInstitute); SPA-1 (Parker Hughes Institute; e.g., SPIKET-P); 3-IAABU(Cytoskeleton/Mt. Sinai School of Medicine; e.g., MF-569); Narcosine(e.g., NSC-5366); Nascapine; D-24851 (Asta Medica); A-105972 (Abbott);Hemiasterlin; 3-BAABU (Cytoskeleton/Mt. Sinai School of Medicine; e.g.,MF-191); TMPN (Arizona State University); Vanadocene acetylacetonate;T-138026 (Tularik); Monsatrol; lnanocine (e.g., NSC-698666); 3-IAABE(Cytoskeleton/Mt. Sinai School of Medicine); A-204197 (Abbott); T-607(Tularik; e.g., T-900607); RPR-115781 (Aventis); Eleutherobins (e.g.,Desmethyleleutherobin; Desaetyleleutherobin; lsoeleutherobin A; andZ-Eleutherobin); Caribaeoside; Caribaeolin; Halichondrin B; D-64131(Asta Medica); D-68144 (Asta Medica); Diazonamide A; A-293620 (Abbott);NPI-2350 (Nereus); Taccalonolide A; TUB-245 (Aventis); A-259754(Abbott); Diozostatin; (−)-Phenylahistin (e.g., NSCL-96F037); D-62638(Asta Medica); D-62636 (Asta Medica); Myoseverin B; D-43411 (Zentaris;e.g., D-81862); A-289099 (Abbott); A-318315 (Abbott); HTI-286 (e.g.,SPA-110; trifluoroacetate salt) (Wyeth); D-82317 (Zentaris); D-82318(Zentaris); SC-12983 (NCI); Resverastatin phosphate sodium; BPR-OY-007(National Health Research Institutes); and SSR-250411 (Sanofi));goserelin; leuprolide; triptolide; homoharringtonine; topotecan;itraconazole; deoxyadenosine; sertraline; pitavastatin; clofazimine;5-nonyloxytryptamine; vemurafenib; dabrafenib; gefitinib (IRESSA);erlotinib (TARCEVA); cetuximab (ERBITUX); lapatinib (TYKERB);panitumumab (VECTIBIX); vandetanib (CAPRELSA); afatinib/BIBW2992;CI-1033/canertinib; neratinib/HKI-272; CP-724714; TAK-285; AST-1306;ARRY334543; ARRY-380; AG-1478; dacomitinib/PF299804; OSI-420/desmethylerlotinib; AZD8931; AEE726; pelitinib/EKB-569; CUDC-101; WZ8040; WZ4002;WZ3146; AG-490; XL647; PD153035; 5-azathioprine; 5-aza-2′-deoxycytidine;17-N-Allylamino-17-Demethoxygeldanamycin (17-AAG); 20-epi-1,25dihydroxyvitamin D3; 5 ethynyluracil; and BMS-599626.

In one aspect is a method for treating patients with colorectal cancer(optionally refractory) by administering an obeticholic acid compositiondescribed herein in combination with capecitabine and/or PLX4032(Plexxikon).

In another aspect is a method for treating colorectal cancer (optionallyrefractory) by administering an obeticholic acid composition describedherein in combination with capecitabine, xeloda, and/or CPT-11.

In another aspect is a method for treating colorectal cancer (optionallyrefractory) by administering an obeticholic acid composition describedherein in combination with capecitabine, xeloda, and/or CPT-11.

In another aspect is a method for treating patients with colorectalcancer (optionally refractory) or patients with unresectable ormetastatic colorectal carcinoma by administering an obeticholic acidcomposition described herein in combination with capecitabine andirinotecan.

In another aspect is a method for treating patients with unresectable ormetastatic hepatocellular carcinoma by administering an obeticholic acidcomposition described herein in combination with interferon alpha orcapecitabin.

In another aspect is a method for treating patients with pancreaticcancer by administering an obeticholic acid composition described hereinin combination with gemcitabine.

Patients described herein include a patients having a disease orcondition described herein. A patient can be described or referred to bythe condition treated. For example, a patient having PBC can be referredto herein as a PBC patient. A patient described herein can have apreexisting condition (e.g., a condition other than the disease orcondition treated by the obeticholic acid composition described hereinthat existed at the time of first administration). In one instance apatient described herein has hepatic impairment. In another instance apatient described herein has renal impairment. In yet another instancethe patient is an elderly/geriatric patient or a pregnant patient. Inanother instance the patient is an pediatric patient.

In some embodiments, administration of an obeticholic acid compositiondescribed herein together with certain contra-active agents can resultin (1) decreased efficacy of the obeticholic acid composition and/or (2)development of toxicity or adverse effects described herein. Forexample, administration of an obeticholic acid composition describedherein with blood clotting and anti-coagulation agents can result indecreased International Normalized Ratio (INR). In certain instances,coagulation and anti-coagulation agents can be administered incombination with an obeticholic acid composition described herein bymonitoring fluctuations of the INR of the patient and adjusting dosagesas understood in the art to maintain proper INR.

In another example, administration of an obeticholic acid compositiondescribed herein in combination with a bile acid binding resin (e.g.,cholestyramine, colestipol, or colesevelam) can result in decreasedefficacy of the obeticholic acid composition at a lower dosage of thecomposition (e.g., 1 to 5 mg). In certain embodiments, a bile acidbinding resin is administered in combination with an obeticholic acidcomposition described herein at least about 4 to 6 hours before or afterthe dosage of the obeticholic acid composition.

In one embodiment, the compositions described herein reduce adverseeffects associated with other formulations (e.g., larger particle sizedobeticholic acid). For example, an obeticholic acid compositiondescribed herein when administered to a patient described herein for acondition or disease described herein can reduce one or more adverseeffects selected from Hepatic encephalopathy, ascites, varicealbleeding, skin eruptions, prurigo, pruritus (including generalized, eye,anal, vulvovaginal and rash), fatigue, asthenia, abdominal pain(including upper and lower pain and tenderness), abdominal discomfort,gastrointestinal pain, dizziness, urticaria (including cholinergic),rashes (including macular, popular, maculo-papular, and heat rashes),arthralgia, oropharyngeal pain, cough, constipation, edemal peripheral,palpitations, pyrexia, eczema, and procedural pain. In certaininstances, the one or more adverse effects that are reduced includepruritus. It was discovered, inter alia, that titration of anobeticholic acid composition described herein can reduce the incidenceof or mean time until onset of severe pruritus.

In another embodiment, the obeticholic acid compositions describedherein include reduced levels of impurities commonly found in thesynthesis of obeticholic acid. 6α-ethylursodeoxycholic acid (6-EUDCA),3α-hydroxy-6α-ethyl-7-keto-5β-cholan-24-oic acid,6β-ethylchenodeoxycholic acid; 3α,7α-dihydroxy-6β-ethyl-5β-cholan-24-oicacid, 3α,7α-dihydroxy-6-ethyliden-5β-cholan-24-oic acid,Chenodeoxycholic acid (CDCA); 3α,7α-dihydroxy-5β-cholan-24-oic acid,Dimer of OCA,3α-(3α,7α-dihydroxy-6α-ethyl-5β-cholan-24-oyloxy)-7α-hydroxy-6α-ethyl-5β-cholan-24-oicacid, or 3α-O-Acetyl-6α-ethylchenodeoxycholic acid;3α-O-acetyl-7α-hydroxy-6α-ethyl-5β-cholan-24-oic acid.

All publications and patent documents cited herein are incorporatedherein by reference as if each such publication or document wasspecifically and individually indicated to be incorporated herein byreference. Citation of publications and patent documents is not intendedas an admission that any is pertinent prior art, nor does it constituteany admission as to the contents or date of the same. The disclosurehaving now been described by way of written description, those of skillin the art will recognize that the disclosure can be practiced in avariety of embodiments and that the foregoing description and examplesbelow are for purposes of illustration and not limitation of the claimsthat follow.

Selected Embodiments Embodiment 1

A method of treating primary biliary cirrhosis (PBC) in a patient inneed thereof, the method comprising administering a compositioncomprising obeticholic acid, or a pharmaceutically acceptable salt,ester, or amino acid conjugate thereof, wherein obeticholic acid or apharmaceutically acceptable salt, ester, or amino acid conjugate thereofis in the form of particles, and wherein at least 50% of the particleshave a diameter of 200 μm or less.

Embodiment 2

A method of treating primary sclerosing cholangitis (PSC), chronic liverdisease, nonalcoholic fatty liver disease (NAFLD), nonalcoholicsteatohepatitis (NASH), hepatitis C infection, alcoholic liver disease,liver damage due to progressive fibrosis, or liver fibrosis in a patientin need thereof, the method comprising administering a compositioncomprising obeticholic acid, or a pharmaceutically acceptable salt,ester, or amino acid conjugate thereof, wherein obeticholic acid or apharmaceutically acceptable salt, ester, or amino acid conjugate thereofis in the form of particles, and wherein at least 50% of the particleshave a diameter of 200 μm or less.

Embodiment 3

The method of embodiment 2, wherein the method comprises treating NASH.

Embodiment 4

A method of treating a solid-tumor cancer in a patient in need thereof,the method comprising administering an effective amount of a compositioncomprising obeticholic acid, or a pharmaceutically acceptable salt,ester, or amino acid conjugate thereof, wherein obeticholic acid or apharmaceutically acceptable salt, ester, or amino acid conjugate thereofis in the form of particles, and wherein at least 50% of the particleshave a diameter of 200 μm or less.

Embodiment 5

The method of embodiment 1, 2 or 4, wherein the effective amountcomprises a starting dose.

Embodiment 6

The method of embodiment 5, wherein the starting dose is administered ina titration period.

Embodiment 7

The method of any one of embodiments 4 to 6, wherein the cancercomprises hepatocellular carcinoma (HCC), colorectal cancer, gastriccancer, liver cancer, kidney cancer, or pancreatic cancer.

Embodiment 8

A method of treating an autoimmune disease in a patient in need thereof,the method comprising administering an effective amount of a compositioncomprising obeticholic acid, or a pharmaceutically acceptable salt,ester, or amino acid conjugate thereof, wherein obeticholic acid or apharmaceutically acceptable salt, ester, or amino acid conjugate thereofis in the form of particles, and wherein at least 50% of the particleshave a diameter of 200 μm or less.

Embodiment 9

The method of embodiment 7, wherein the effective amount comprises astarting dose.

Embodiment 10

The method of embodiment 8, wherein the starting dose is administered ina titration period.

Embodiment 11

The method of embodiment 7 or 8, wherein the autoimmune disease isselected from the group consisting of: PBC, multiple sclerosis,rheumatoid arthritis, and type-I diabetes.

Embodiment 12

The method of any one of embodiments 1-2, 6 or 9, wherein the titrationperiod comprises 1 to 6 months.

Embodiment 13

The method of embodiment 11, wherein the titration period is 3 months.

Embodiment 14

The method of embodiment 11, wherein the titration period is 6 months.

Embodiment 15

The method of any one of embodiments 12 to 15, wherein the starting doseis administered to the patient once daily.

Embodiment 16

The method of any one of embodiments 11 to 14, wherein the starting doseis administered to the patient once daily.

Embodiment 17

The method of any one of embodiments 11 to 14, wherein the starting doseis administered to the patient once weekly.

Embodiment 18

The method of any one of embodiments 11 to 14, wherein the starting doseis administered to the patient once every other day.

Embodiment 19

The method of any one of embodiments 11 to 17, wherein the starting dosecomprises about 1 mg to 50 mg.

Embodiment 20

The method of any one of embodiments 11 to 17, wherein the starting dosecomprises about 1 mg to 25 mg.

Embodiment 21

The method of any one of embodiments 11 to 17, wherein the starting dosecomprises about 1 mg to 10 mg.

Embodiment 22

The method of any one of embodiments 11 to 17, wherein the starting dosecomprises about 1 mg to 5 mg.

Embodiment 23

The method of any one of embodiments 11 to 17, wherein the starting dosecomprises about 5 mg.

Embodiment 24

The method of any one of embodiments 11 to 17, wherein the starting dosecomprises about 10 mg.

Embodiment 25

The method of any one of embodiments 11 to 17, wherein the starting dosecomprises about 25 mg.

Embodiment 26

The method of any one of embodiments 11 to 17, wherein the starting dosecomprises about 50 mg.

Embodiment 27

The method of any one of embodiments 1 to 26, further comprisingassessing or monitoring liver function before, during, or after thetitration period.

Embodiment 28

The method of embodiment 27, wherein the assessing or monitoringcomprises measuring a level of one or more liver biomarkers compared toa control.

Embodiment 29

The method of embodiment 28, wherein the liver biomarker is selectedfrom the group consisting of: AST, ALT, alkaline phosphatase (ALP),bilirubin, glycine conjugated obeticholic acid, taurine conjugatedobeticholic acid, a bile acid, a bile acid glycine conjugate, or a bileacid taurine conjugate.

Embodiment 30

The method of embodiment 29, comprising detecting a level of ALP in thepatient.

Embodiment 31

The method of embodiment 29 or 30, comprising detecting a level ofbilirubin in the patient.

Embodiment 32

The method of any one of embodiments 27 to 31, further comprisingcalculating a AST to platelet ratio (APRI) for the patient.

Embodiment 33

The method of any one of embodiments 12 to 32, wherein the obeticholicacid composition is administered to the patient as an adjusted doseafter the titration period.

Embodiment 34

The method of embodiment 33, wherein the adjusted dose is equal to thetitrated dose.

Embodiment 35

The method of embodiment 33, wherein the adjusted dose is equal to thestarting dose when the level of ALP is reduced compared to a control.

Embodiment 36

The method of embodiment 33, wherein the adjusted dose is greater thanthe titrated dose.

Embodiment 37

The method of any one of embodiments 33 to 36, wherein the adjusted doseis administered more frequently than the titrated dose.

Embodiment 38

The method of any one of embodiments 33 to 36, wherein the adjusted doseis administered less frequently than the titrated dose.

Embodiment 39

The method of any one of embodiments 33 to 38, wherein the adjusted doseof the obeticholic acid composition is administered to the patient oncedaily.

Embodiment 40

The method of any one of embodiments 33 to 38, wherein the adjusted doseof the obeticholic acid composition is administered to the patient oncedaily.

Embodiment 41

The method of any one of embodiments 33 to 38, wherein the adjusted doseof the obeticholic acid composition is administered to the patient oncedaily.

Embodiment 42

The method of any one of embodiments 33 to 38, wherein the adjusted doseof the obeticholic acid composition is administered to the patient onceweekly.

Embodiment 43

The method of any one of embodiments 33 to 38, wherein the adjusted doseof the obeticholic acid composition is administered to the patient onceevery other day.

Embodiment 44

The method of any one of embodiments 33 to 38, wherein the adjusted doseof the obeticholic acid composition is administered to the patient twicea week.

Embodiment 45

The method of any one of embodiments 33 to 44, wherein the adjusted dosecomprises about 1 mg to 50 mg.

Embodiment 46

The method of any one of embodiments 33 to 44, wherein the adjusted dosecomprises about 1 mg to 25 mg.

Embodiment 47

The method of any one of embodiments 33 to 44, wherein the adjusted dosecomprises about 1 mg to 10 mg.

Embodiment 48

The method of any one of embodiments 33 to 44, wherein the adjusted dosecomprises about 1 mg to 5 mg.

Embodiment 49

The method of any one of embodiments 33 to 44, wherein the adjusted dosecomprises about 5 mg.

Embodiment 50

The method of any one of embodiments 33 to 44, wherein the adjusted dosecomprises about 10 mg.

Embodiment 51

The method of any one of embodiments 33 to 44, wherein the adjusted dosecomprises about 25 mg.

Embodiment 52

The method of any one of embodiments 33 to 44, wherein the adjusted dosecomprises about 50 mg.

Embodiment 53

The method of any one of embodiments 1 to 52, wherein the method furthercomprises administering one or more active agents, or combinationsthereof.

Embodiment 54

The method of embodiment 53, wherein the active agent is ursodeoxycholicacid (UDCA).

Embodiment 55

The method of embodiment 53, wherein the active agent is a peroxisomeproliferator-activated receptor alpha (PPARα) agonist, a peroxisomeproliferator-activated receptor delta (PPARδ) agonist, a dual PPARα/δagonist, a dual PPARα/γ agonist, or pan-PPAR agonist, an HMG CoAreductase inhibitor, a GLP1 agonist, insulin, insulin mimetic,metformin, a GTP4 agonist, an HST2 inhibitor, a DPP-IV inhibitor, anSGLT2 inhibitor or a hydroxysteroid dehydrogenase (HSD) inhibitor, suchas an 11β-HSD1 inhibitor, an ASK1 inhibitor, an ACC1 inhibitor, a NOX1and/or NOX4 inhibitor, an inhibitor or antagonist of one or morechemokine receptors, such as, for example, CCR2 and CCR5.

Embodiment 56

The method of any one of embodiments 1 to 55, wherein the obeticholicacid composition is administered as a first line therapy for thetreatment of PBC.

Embodiment 57

The method of any one of embodiments 1 to 56, wherein the patient is hasrenal impairment or hepatic impairment.

Embodiment 58

A method for treating primary biliary cirrhosis (PBC) in a patient inneed thereof, the method comprising:

administering a starting dose of a composition comprising obeticholicacid, or a pharmaceutically acceptable salt, ester, or amino acidconjugate thereof, in a titration period, wherein obeticholic acid or apharmaceutically acceptable salt, ester, or amino acid conjugate thereofis in the form of particles, and wherein at least 50% of the particleshave a diameter of 200 μm or less;

assessing liver function of the patient before, during, and after thetitration period by: calculating an AST to platelet ratio (APRI) scorefor the patient; or measuring the level of one or more liver biomarkerselected from ALP, bilirubin, AST, ALT, glycine conjugated obeticholicacid, taurine conjugated obeticholic acid, a bile acid, a bile acidglycine conjugate, or a bile acid taurine conjugate;wherein a reduced APRI score compared to a control or a reduced level ofthe one or more liver biomarkers compared to a control indicatesnon-impaired liver function;assessing tolerance of the patient to the starting dose by grading theseverity of one or more adverse effects, if present; andadministering an adjusted dose of the obeticholic acid composition,wherein the adjusted dose comprises an amount equal to or greater thanan amount of the starting dose.

Embodiment 59

The method of embodiment 58, wherein the adjusted dose is administeredat an amount equal to an amount of the starting dose.

Embodiment 60

The method of embodiment 58, wherein the adjusted dose is administeredat an amount greater than an amount of the starting dose.

Embodiment 61

The method of embodiment 58, wherein the adjusted dose of theobeticholic acid composition is administered at the same frequency asthe starting dose.

Embodiment 62

The method of embodiment 58, wherein the adjusted dose of theobeticholic acid composition is administered at a decreased frequencythan the starting dose.

Embodiment 63

The method of embodiment 58, wherein the effective amount of theobeticholic acid composition is administered at an increased frequencythan the starting dose.

Embodiment 64

The method of any one of embodiments 58 to 63, wherein the starting doseis 5 mg.

Embodiment 65

The method of any one of embodiments 58 to 64, wherein the starting doseis administered QD.

Embodiment 66

The method of any one of embodiments 58 to 64, wherein the adjusted doseis 5 mg.

Embodiment 67

The method of any one of embodiments 58 to 64, wherein the adjusted doseis 10 mg.

Embodiment 68

The method of any one of embodiments 58 to 67, wherein the adjusted doseis administered QD or Q2D.

Embodiment 69

The method of any one of embodiments 58 to 68, further comprisingassessing the patient for tolerance to the adjusted dose.

Embodiment 70

The method of embodiment 69, wherein the adjusted dose is modified to are-adjusted dose when the patient.

Embodiment 71

The method of embodiment 70, wherein the re-adjusted dose comprises anequal amount compared to the adjusted dose and administration at areduced frequency.

Embodiment 72

The method of embodiment 71, wherein the re-adjusted dose comprises areduced amount compared to the adjusted dose and administration at anequal frequency.

Embodiment 73

The method of embodiment 58, wherein the patient has hepatic impairment.

Embodiment 74

The method of embodiment 73, wherein the starting dose is administeredQW.

Embodiment 75

The method of embodiment 74, wherein the starting dose is 5 mg.

Embodiment 75

The method of any one of embodiments 58 to 75, wherein the adjusted doseis equivalent to the starting dose when the level of ALP is reducedcompared to a control.

Embodiment 76

The method of any one of embodiments 58 to 75, wherein the adjusted dosecomprises an amount equal to the starting dose and wherein the adjusteddose is administered at a greater frequency than the starting dose.

Embodiment 77

A composition comprising obeticholic acid, or a pharmaceuticallyacceptable salt, ester, or amino acid conjugate thereof, whereinobeticholic acid or a pharmaceutically acceptable salt, ester, or aminoacid conjugate thereof is in the form of particles, and wherein at least50% of the particles have a diameter of 200 μm or less, for use intreating primary biliary cirrhosis (PBC) in a patient in need thereof.

Embodiment 78

A composition comprising obeticholic acid, or a pharmaceuticallyacceptable salt, ester, or amino acid conjugate thereof, whereinobeticholic acid or a pharmaceutically acceptable salt, ester, or aminoacid conjugate thereof is in the form of particles, and wherein at least50% of the particles have a diameter of 200 μm or less, for use intreating primary biliary cirrhosis (PBC) in a patient in need thereof.

Embodiment 79

A composition comprising obeticholic acid, or a pharmaceuticallyacceptable salt, ester, or amino acid conjugate thereof, whereinobeticholic acid or a pharmaceutically acceptable salt, ester, or aminoacid conjugate thereof is in the form of particles, and wherein at least50% of the particles have a diameter of 200 μm or less, for use intreating primary sclerosing cholangitis (PSC), chronic liver disease,nonalcoholic fatty liver disease (NAFLD), nonalcoholic steatohepatitis(NASH), hepatitis C infection, alcoholic liver disease, liver damage dueto progressive fibrosis, or liver fibrosis in a patient in need thereofin a patient in need thereof.

Embodiment 80

The composition of embodiment 79, for use in treating NASH.

Embodiment 81

A composition comprising obeticholic acid, or a pharmaceuticallyacceptable salt, ester, or amino acid conjugate thereof, whereinobeticholic acid or a pharmaceutically acceptable salt, ester, or aminoacid conjugate thereof is in the form of particles, and wherein at least50% of the particles have a diameter of 200 μm or less, for use intreating a solid-tumor cancer in a patient in need thereof.

Embodiment 82

The composition of embodiments 77, 79 or 81, wherein said compositionfurther comprises said obeticholic acid composition as a starting dose.

Embodiment 83

The composition of embodiment 82, wherein said starting dose is preparedto be administered in a titration period.

Embodiment 84

The composition of any one of embodiments 81 to 83, for use in treatinghepatocellular carcinoma (HCC), colorectal cancer, gastric cancer, livercancer, kidney cancer, or pancreatic cancer.

Embodiment 85

A composition comprising obeticholic acid, or a pharmaceuticallyacceptable salt, ester, or amino acid conjugate thereof, whereinobeticholic acid or a pharmaceutically acceptable salt, ester, or aminoacid conjugate thereof is in the form of particles, and wherein at least50% of the particles have a diameter of 200 μm or less, for use intreating an autoimmune disease in a patient in need thereof.

Embodiment 86

The composition of embodiment 85, wherein said composition furthercomprises said obeticholic acid composition as a starting dose.

Embodiment 87

The composition of embodiment 86, wherein said starting dose is preparedto be administered in a titration period.

Embodiment 88

The composition of embodiment 85 or 86, for use in treating multiplesclerosis, rheumatoid arthritis, or type-I diabetes.

Embodiment 89

The composition of any one of embodiments 78-79, 83 or 87, wherein saidtitration period comprises 1 to 6 months.

Embodiment 90

The composition of embodiment 89, wherein said titration period is 3months.

Embodiment 91

The composition of embodiment 89, wherein said titration period is 6months.

Embodiment 92

The composition of any one of embodiments 89 to 91, wherein saidstarting dose is prepared to be administered to said patient once daily.

Embodiment 93

The composition of any one of embodiments 89 to 92, wherein saidstarting dose is prepared to be administered to said patient once daily.

Embodiment 94

The composition of any one of embodiments 89 to 92, wherein saidstarting dose is prepared to be administered to said patient onceweekly.

Embodiment 95

The composition of any one of embodiments 89 to 92, wherein saidstarting dose is prepared to be administered to said patient once everyother day.

Embodiment 96

The composition of any one of embodiments 89 to 95, wherein saidstarting dose comprises about 1 mg to 50 mg.

Embodiment 97

The composition of any one of embodiments 89 to 95, wherein saidstarting dose comprises about 1 mg to 25 mg.

Embodiment 98

The composition of any one of embodiments 89 to 95, wherein saidstarting dose comprises about 1 mg to 10 mg.

Embodiment 99

The composition of any one of embodiments 89 to 95, wherein saidstarting dose comprises about 1 mg to 5 mg.

Embodiment 100

The composition of any one of embodiments 89 to 95, wherein saidstarting dose comprises about 5 mg.

Embodiment 101

The composition of any one of embodiments 89 to 95, wherein saidstarting dose comprises about 10 mg.

Embodiment 102

The composition of any one of embodiments 89 to 95, wherein saidstarting dose comprises about 25 mg.

Embodiment 103

The composition of any one of embodiments 89 to 95, wherein saidstarting dose comprises about 50 mg.

Embodiment 104

The composition of any one of embodiments 78 to 103, wherein saidpatient liver function assessed or monitored before, during, or aftersaid titration period.

Embodiment 105

The composition of embodiment 104, wherein said assessing or monitoringcomprises measuring a level of one or more liver biomarkers compared toa control.

Embodiment 106

The composition of embodiment 105, wherein said liver biomarker isselected from the group consisting of: AST, ALT, alkaline phosphatase(ALP), bilirubin, glycine conjugated obeticholic acid, taurineconjugated obeticholic acid, a bile acid, a bile acid glycine conjugate,or a bile acid taurine conjugate.

Embodiment 107

The composition of embodiment 106, wherein said liver biomarker is ALP.

Embodiment 108

The composition of embodiment 106 or 107, wherein said liver biomarkeris bilirubin.

Embodiment 109

The composition of any one of embodiments 104 to 108, further comprisingcalculating an AST to platelet ratio (APRI) for said patient.

Embodiment 110

The composition of any one of embodiments 89 to 109, wherein saidobeticholic acid composition is prepared to be administered to saidpatient as an adjusted dose after said titration period.

Embodiment 111

The composition of embodiment 110, wherein said adjusted dose is equalto said titrated dose.

Embodiment 112

The composition of embodiment 110, wherein said adjusted dose is equalto said starting dose when a level of ALP is reduced compared to acontrol.

Embodiment 113

The composition of embodiment 110, wherein said adjusted dose is greaterthan said titrated dose.

Embodiment 114

The composition of any one of embodiments 110 to 113, wherein saidadjusted dose is prepared to be administered more frequently than saidtitrated dose.

Embodiment 115

The composition of any one of embodiments 110 to 113, wherein saidadjusted dose is prepared to be administered less frequently than saidtitrated dose.

Embodiment 116

The composition of any one of embodiments 110 to 115, wherein saidadjusted dose of said obeticholic acid composition is prepared to beadministered to said patient once daily.

Embodiment 117

The composition of any one of embodiments 110 to 115, wherein saidadjusted dose of said obeticholic acid composition is prepared to beadministered to said patient once daily.

Embodiment 118

The composition of any one of embodiments 110 to 115, wherein saidadjusted dose of said obeticholic acid composition is prepared to beadministered to said patient once daily.

Embodiment 119

The composition of any one of embodiments 110 to 115, wherein saidadjusted dose of said obeticholic acid composition is prepared to beadministered to said patient once weekly.

Embodiment 120

The composition of any one of embodiments 110 to 115, wherein saidadjusted dose of said obeticholic acid composition is prepared to beadministered to said patient once every other day.

Embodiment 121

The composition of any one of embodiments 110 to 115, wherein saidadjusted dose of said obeticholic acid composition is prepared to beadministered to said patient twice a week.

Embodiment 122

The composition of any one of embodiments 110 to 121, wherein saidadjusted dose comprises about 1 mg to 50 mg.

Embodiment 123

The composition of any one of embodiments 110 to 121, wherein saidadjusted dose comprises about 1 mg to 25 mg.

Embodiment 124

The composition of any one of embodiments 110 to 121, wherein saidadjusted dose comprises about 1 mg to 10 mg.

Embodiment 125

The composition of any one of embodiments 110 to 121, wherein saidadjusted dose comprises about 1 mg to 5 mg.

Embodiment 126

The composition of any one of embodiments 110 to 121, wherein saidadjusted dose comprises about 5 mg.

Embodiment 127

The composition of any one of embodiments 110 to 121, wherein saidadjusted dose comprises about 10 mg.

Embodiment 128

The composition of any one of embodiments 110 to 121, wherein saidadjusted dose comprises about 25 mg.

Embodiment 129

The composition of any one of embodiments 110 to 121, wherein saidadjusted dose comprises about 50 mg.

Embodiment 130

The composition of any one of embodiments 78 to 129, wherein saidobeticholic acid composition is prepared to be co-administered one ormore active agents, or combinations thereof.

Embodiment 131

The composition of embodiment 130, wherein said active agent isursodeoxycholic acid (UDCA).

Embodiment 132

The composition of embodiment 130, wherein the active agent is aperoxisome proliferator-activated receptor alpha (PPARα) agonist, aperoxisome proliferator-activated receptor delta (PPARδ) agonist, a dualPPARα/δ agonist, a dual PPARα/γ agonist, or pan-PPAR agonist, an HMG CoAreductase inhibitor, a GLP1 agonist, insulin, insulin mimetic,metformin, a GTP4 agonist, an HST2 inhibitor, a DPP-IV inhibitor, anSGLT2 inhibitor or a hydroxysteroid dehydrogenase (HSD) inhibitor, suchas an 11β-HSD1 inhibitor, an ASK1 inhibitor, an ACC1 inhibitor, a NOX1and/or NOX4 inhibitor, an inhibitor or antagonist of one or morechemokine receptors, such as, for example, CCR2 and CCR5.

Embodiment 133

The composition of any one of embodiments 78 to 132, wherein saidobeticholic acid composition is prepared to be administered as a firstline therapy for the treatment of PBC.

Embodiment 134

The composition of any one of embodiments 78 to 133, wherein saidpatient is has renal impairment or hepatic impairment.

Embodiment 135

A composition comprising a starting dose of obeticholic acid, or apharmaceutically acceptable salt, ester, or amino acid conjugatethereof, wherein obeticholic acid or a pharmaceutically acceptable salt,ester, or amino acid conjugate thereof is in the form of particles, andwherein at least 50% of the particles have a diameter of 200 μm or lessfor use in treating primary biliary cirrhosis (PBC) in a patient in needthereof wherein the composition is prepared to be administered in atitration period wherein

the liver function of the patient is assessed before, during, and aftersaid titration period by calculating an AST to platelet ratio (APRI)score for said patient or by measuring the level of one or more liverbiomarker selected from ALP, bilirubin, AST, ALT, glycine conjugatedobeticholic acid, taurine conjugated obeticholic acid, a bile acid, abile acid glycine conjugate, or a bile acid taurine conjugate, wherein areduced APRI score compared to a control or a reduced level of said oneor more liver biomarkers compared to a control indicates non-impairedliver function; and

the tolerance of the patient to said starting dose is assessed bygrading the severity of one or more adverse effects, if present; and theobeticholic acid composition is prepared to be administered as anadjusted dose, wherein said adjusted dose comprises an amount equal toor greater than an amount of said starting dose.

Embodiment 136

The composition of embodiment 135, wherein said adjusted dose isprepared to be administered at an amount equal to an amount of saidstarting dose.

Embodiment 137

The composition of embodiment 135, wherein said adjusted dose isprepared to be administered at an amount greater than an amount of saidstarting dose.

Embodiment 138

The composition of embodiment 135, wherein said adjusted dose of saidobeticholic acid composition is prepared to be administered at the samefrequency as said starting dose.

Embodiment 139

The composition of embodiment 135, wherein said adjusted dose of saidobeticholic acid composition is prepared to be administered at adecreased frequency than said starting dose.

Embodiment 140

The composition of embodiment 135, wherein said effective amount of saidobeticholic acid composition is prepared to be administered at anincreased frequency than said starting dose.

Embodiment 141

The composition of any one of embodiments 135 to 140, wherein saidstarting dose is 5 mg.

Embodiment 142

The composition of any one of embodiments 135 to 141, wherein saidstarting dose is prepared to be administered QD.

Embodiment 143

The composition of any one of embodiments 135 to 141, wherein saidadjusted dose is 5 mg.

Embodiment 144

The composition of any one of embodiments 135 to 141, wherein saidadjusted dose is 10 mg.

Embodiment 145

The composition of any one of embodiments 135 to 144, wherein saidadjusted dose is prepared to be administered QD or Q2D.

Embodiment 146

The composition of any one of embodiments 135 to 145, wherein saidpatient is assessed for tolerance to said adjusted dose.

Embodiment 147

The composition of embodiment 146, wherein said adjusted dose ismodified to a re-adjusted dose.

Embodiment 148

The composition of embodiment 147, wherein said re-adjusted dosecomprises an equal amount compared to said adjusted dose and is preparedto be administrated at a reduced frequency.

Embodiment 149

The composition of embodiment 148, wherein said re-adjusted dosecomprises a reduced amount compared to said adjusted dose and isprepared to be administrated at an equal frequency.

Embodiment 150

The composition of embodiment 135, wherein said patient has hepaticimpairment.

Embodiment 151

The composition of embodiment 150, wherein said starting dose isprepared to be administered QW.

Embodiment 152

The composition of embodiment 151, wherein said starting dose is 5 mg.

Embodiment 153

The composition of any one of embodiments 135 to 152, wherein saidadjusted dose is equivalent to said starting dose when said level of ALPis reduced compared to a control.

Embodiment 154

The composition of any one of embodiments 135 to 152, wherein saidadjusted dose comprises an amount equal to said starting dose andwherein said adjusted dose is prepared to be administered at a greaterfrequency than said starting dose.

Embodiment 155

Use of a composition comprising obeticholic acid, or a pharmaceuticallyacceptable salt, ester, or amino acid conjugate thereof, whereinobeticholic acid or a pharmaceutically acceptable salt, ester, or aminoacid conjugate thereof is in the form of particles, and wherein at least50% of the particles have a diameter of 200 μm or less, for themanufacture of a medicament for use in treating primary biliarycirrhosis (PBC) in a patient in need thereof.

Embodiment 156

Use of a composition comprising obeticholic acid, or a pharmaceuticallyacceptable salt, ester, or amino acid conjugate thereof, whereinobeticholic acid or a pharmaceutically acceptable salt, ester, or aminoacid conjugate thereof is in the form of particles, and wherein at least50% of the particles have a diameter of 200 μm or less, for themanufacture of a medicament for use in treating primary sclerosingcholangitis (PSC), chronic liver disease, nonalcoholic fatty liverdisease (NAFLD), nonalcoholic steatohepatitis (NASH), hepatitis Cinfection, alcoholic liver disease, liver damage due to progressivefibrosis, or liver fibrosis in a patient in need thereof in a patient inneed thereof.

Embodiment 157

The use of embodiment 156, for use in treating NASH.

Embodiment 158

Use of a composition comprising obeticholic acid, or a pharmaceuticallyacceptable salt, ester, or amino acid conjugate thereof, whereinobeticholic acid or a pharmaceutically acceptable salt, ester, or aminoacid conjugate thereof is in the form of particles, and wherein at least50% of the particles have a diameter of 200 μm or less, for themanufacture of a medicament for use in treating a solid-tumor cancer ina patient in need thereof.

Embodiment 159

The use of embodiments 155, 156 or 158, wherein said composition furthercomprises said obeticholic acid composition as a starting dose.

Embodiment 160

The use of embodiment 159, wherein said starting dose is prepared to beadministered in a titration period.

Embodiment 161

The use of any one of embodiments 158 to 160, wherein said cancer ishepatocellular carcinoma (HCC), colorectal cancer, gastric cancer, livercancer, kidney cancer, or pancreatic cancer.

Embodiment 162

Use of a composition comprising obeticholic acid, or a pharmaceuticallyacceptable salt, ester, or amino acid conjugate thereof, whereinobeticholic acid or a pharmaceutically acceptable salt, ester, or aminoacid conjugate thereof is in the form of particles, and wherein at least50% of the particles have a diameter of 200 μm or less, for themanufacture of a medicament for use in treating an autoimmune disease ina patient in need thereof.

Embodiment 163

The use of embodiment 162, wherein said obeticholic acid composition isprepared to be administered as a starting dose.

Embodiment 164

The use of embodiment 163, wherein said starting dose is prepared to beadministered in a titration period.

Embodiment 165

The use of embodiment 162 or 163, wherein said autoimmune disease ismultiple sclerosis, rheumatoid arthritis, or type-I diabetes.

Embodiment 166

The use of any one of embodiments 155-156, 160 or 164, wherein saidtitration period comprises 1 to 6 months.

Embodiment 167

The use of embodiment 166, wherein said titration period is 3 months.

Embodiment 168

The use of embodiment 166, wherein said titration period is 6 months.

Embodiment 169

The use of any one of embodiments 166 to 168, wherein said starting doseis prepared to be administered to said patient once daily.

Embodiment 170

The use of any one of embodiments 166 to 169, wherein said starting doseis prepared to be administered to said patient once daily.

Embodiment 171

The use of any one of embodiments 166 to 169, wherein said starting doseis prepared to be administered to said patient once weekly.

Embodiment 172

The use of any one of embodiments 166 to 169, wherein said starting doseis prepared to be administered to said patient once every other day.

Embodiment 173

The use of any one of embodiments 166 to 172, wherein said starting dosecomprises about 1 mg to 50 mg.

Embodiment 174

The use of any one of embodiments 166 to 172, wherein said starting dosecomprises about 1 mg to 25 mg.

Embodiment 175

The use of any one of embodiments 166 to 172, wherein said starting dosecomprises about 1 mg to 10 mg.

Embodiment 176

The use of any one of embodiments 166 to 172, wherein said starting dosecomprises about 1 mg to 5 mg.

Embodiment 177

The use of any one of embodiments 166 to 172, wherein said starting dosecomprises about 5 mg.

Embodiment 178

The use of any one of embodiments 166 to 172, wherein said starting dosecomprises about 10 mg.

Embodiment 179

The use of any one of embodiments 166 to 172, wherein said starting dosecomprises about 25 mg.

Embodiment 180

The use of any one of embodiments 166 to 172, wherein said starting dosecomprises about 50 mg.

Embodiment 181

The use of any one of embodiments 155 to 180, wherein liver function ofsaid patient is assessed or monitored before, during, or after saidtitration period.

Embodiment 182

The use of embodiment 181, wherein said assessing or monitoringcomprises measuring a level of one or more liver biomarkers compared toa control.

Embodiment 183

The use of embodiment 182, wherein said liver biomarker is selected fromthe group consisting of: AST, ALT, alkaline phosphatase (ALP),bilirubin, glycine conjugated obeticholic acid, taurine conjugatedobeticholic acid, a bile acid, a bile acid glycine conjugate, or a bileacid taurine conjugate.

Embodiment 184

The use of embodiment 183, wherein said liver biomarker is ALP.

Embodiment 185

The use of embodiment 183 or 184, wherein said liver biomarker isbilirubin.

Embodiment 186

The use of any one of embodiments 181 to 185, further comprisingcalculating an AST to platelet ratio (APRI) for said patient.

Embodiment 187

The use of any one of embodiments 166 to 186, wherein said obeticholicacid composition is prepared to be administered to said patient as anadjusted dose after said titration period.

Embodiment 188

The use of embodiment 187, wherein said adjusted dose is equal to saidtitrated dose.

Embodiment 189

The use of embodiment 187, wherein said adjusted dose is equal to saidstarting dose when a level of ALP is reduced compared to a control.

Embodiment 190

The use of embodiment 187, wherein said adjusted dose is greater thansaid titrated dose.

Embodiment 191

The use of any one of embodiments 187 to 190, wherein said adjusted doseis prepared to be administered more frequently than said titrated dose.

Embodiment 192

The use of any one of embodiments 187 to 190, wherein said adjusted doseis prepared to be administered less frequently than said titrated dose.

Embodiment 193

The use of any one of embodiments 187 to 192, wherein said adjusted doseof said obeticholic acid composition is prepared to be administered tosaid patient once daily.

Embodiment 194

The use of any one of embodiments 187 to 192, wherein said adjusted doseof said obeticholic acid composition is prepared to be administered tosaid patient once daily.

Embodiment 195

The use of any one of embodiments 187 to 192, wherein said adjusted doseof said obeticholic acid composition is prepared to be administered tosaid patient once daily.

Embodiment 196

The use of any one of embodiments 187 to 192, wherein said adjusted doseof said obeticholic acid composition is prepared to be administered tosaid patient once weekly.

Embodiment 197

The use of any one of embodiments 187 to 192, wherein said adjusted doseof said obeticholic acid composition is prepared to be administered tosaid patient once every other day.

Embodiment 198

The use of any one of embodiments 187 to 192, wherein said adjusted doseof said obeticholic acid composition is prepared to be administered tosaid patient twice a week.

Embodiment 199

The use of any one of embodiments 187 to 198, wherein said adjusted dosecomprises about 1 mg to 50 mg.

Embodiment 200

The use of any one of embodiments 187 to 198, wherein said adjusted dosecomprises about 1 mg to 25 mg.

Embodiment 201

The use of any one of embodiments 187 to 198, wherein said adjusted dosecomprises about 1 mg to 10 mg.

Embodiment 202

The use of any one of embodiments 187 to 198, wherein said adjusted dosecomprises about 1 mg to 5 mg.

Embodiment 203

The use of any one of embodiments 187 to 198, wherein said adjusted dosecomprises about 5 mg.

Embodiment 204

The use of any one of embodiments 187 to 198, wherein said adjusted dosecomprises about 10 mg.

Embodiment 205

The use of any one of embodiments 187 to 198, wherein said adjusted dosecomprises about 25 mg.

Embodiment 206

The use of any one of embodiments 187 to 198, wherein said adjusted dosecomprises about 50 mg.

Embodiment 207

The use of any one of embodiments 155 to 206, wherein said obeticholicacid composition is prepared to be administered in combination with oneor more active agents, or combinations thereof.

Embodiment 208

The use of embodiment 207, wherein said active agent is ursodeoxycholicacid (UDCA).

Embodiment 209

The use of embodiment 207, wherein the active agent is a peroxisomeproliferator-activated receptor alpha (PPARα) agonist, a peroxisomeproliferator-activated receptor delta (PPARδ) agonist, a dual PPARα/δagonist, a dual PPARα/γ agonist, or pan-PPAR agonist, an HMG CoAreductase inhibitor, a GLP1 agonist, insulin, insulin mimetic,metformin, a GTP4 agonist, an HST2 inhibitor, a DPP-IV inhibitor, anSGLT2 inhibitor or a hydroxysteroid dehydrogenase (HSD) inhibitor, suchas an 11β-HSD1 inhibitor, an ASK1 inhibitor, an ACC1 inhibitor, a NOX1and/or NOX4 inhibitor, an inhibitor or antagonist of one or morechemokine receptors, such as, for example, CCR2 and CCR5.

Embodiment 210

The use of any one of embodiments 155 to 209, wherein said obeticholicacid composition is prepared to be administered as a first line therapyfor the treatment of PBC.

Embodiment 211

The use of any one of embodiments 155 to 210, wherein said patient ishas renal impairment or hepatic impairment.

Embodiment 212

The use of a composition comprising a starting dose of obeticholic acid,or a pharmaceutically acceptable salt, ester, or amino acid conjugatethereof, wherein obeticholic acid or a pharmaceutically acceptable salt,ester, or amino acid conjugate thereof is in the form of particles, andwherein at least 50% of the particles have a diameter of 200 μm or lessfor use in treating primary biliary cirrhosis (PBC) in a patient in needthereof wherein the composition is prepared to be administered in atitration period wherein:

the liver function of the patient is assessed before, during, and aftersaid titration period by calculating an AST to platelet ratio (APRI)score for said patient or by measuring the level of one or more liverbiomarker selected from ALP, bilirubin, AST, ALT, glycine conjugatedobeticholic acid, taurine conjugated obeticholic acid, a bile acid, abile acid glycine conjugate, or a bile acid taurine conjugate, wherein areduced APRI score compared to a control or a reduced level of said oneor more liver biomarkers compared to a control indicates non-impairedliver function; andthe tolerance of the patient to said starting dose is assessed bygrading the severity of one or more adverse effects, if present; and theobeticholic acid composition is prepared to be administered as anadjusted dose, wherein said adjusted dose comprises an amount equal toor greater than an amount of said starting dose.

Embodiment 213

The use of embodiment 212, wherein said adjusted dose is prepared to beadministered at an amount equal to an amount of said starting dose.

Embodiment 214

The use of embodiment 212, wherein said adjusted dose is prepared to beadministered at an amount greater than an amount of said starting dose.

Embodiment 215

The use of embodiment 212, wherein said adjusted dose of saidobeticholic acid composition is prepared to be administered at the samefrequency as said starting dose.

Embodiment 216

The use of embodiment 212, wherein said adjusted dose of saidobeticholic acid composition is prepared to be administered at adecreased frequency than said starting dose.

Embodiment 217

The use of embodiment 212, wherein said effective amount of saidobeticholic acid composition is prepared to be administered at anincreased frequency than said starting dose.

Embodiment 218

The use of any one of embodiments 212 to 217, wherein said starting doseis 5 mg.

Embodiment 219

The use of any one of embodiments 212 to 218, wherein said starting doseis prepared to be administered QD.

Embodiment 220

The use of any one of embodiments 212 to 218, wherein said adjusted doseis 5 mg.

Embodiment 221

The use of any one of embodiments 212 to 218, wherein said adjusted doseis 10 mg.

Embodiment 222

The use of any one of embodiments 212 to 221, wherein said adjusted doseis prepared to be administered QD or Q2D.

Embodiment 223

The use of any one of embodiments 212 to 222, wherein said patient isassessed for tolerance to said adjusted dose.

Embodiment 224

The use of embodiment 223, wherein said adjusted dose is modified to are-adjusted dose.

Embodiment 225

The use of embodiment 224, wherein said re-adjusted dose comprises anequal amount compared to said adjusted dose and is prepared to beadministrated at a reduced frequency.

Embodiment 226

The use of embodiment 225, wherein said re-adjusted dose comprises areduced amount compared to said adjusted dose and is prepared to beadministrated at an equal frequency.

Embodiment 227

The use of embodiment 212, wherein said patient has hepatic impairment.

Embodiment 228

The use of embodiment 227, wherein said starting dose is prepared to beadministered QW.

Embodiment 229

The use of embodiment 228, wherein said starting dose is 5 mg.

Embodiment 230

The use of any one of embodiments 212 to 229, wherein said adjusted doseis equivalent to said starting dose when said level of ALP is reducedcompared to a control.

Embodiment 231

The use of any one of embodiments 212 to 229, wherein said adjusted dosecomprises an amount equal to said starting dose and wherein saidadjusted dose is prepared to be administered at a greater frequency thansaid starting dose.

EXAMPLES

The disclosure is further illustrated by the following examples, whichare not to be construed as limiting this disclosure in scope or spiritto the specific procedures herein described. It is to be understood thatthe examples are provided to illustrate certain embodiments and that nolimitation to the scope of the disclosure is intended. It is to befurther understood that resort may be had to various other embodiments,modifications, and equivalents thereof which may suggest themselves tothose skilled in the art without departing from the spirit of thepresent disclosure and/or scope of the appended claims.

Example 1 Particle Size Analysis

5 mg tablet and 10 mg tablet formulations of obeticholic acid (OCA orINT-747) demonstrated a slow dissolution release profile. Particle sizeof agglomeration was identified as playing a primary role in the releaserate and dissolution and variability in the blend uniformity and contentuniformity of the tablet formulations. In order to obtain an appropriateparticle size distribution (PSD), milling of obeticholic acid wasinvestigated. The particle size of the formulations was reduced usingcomilling and jet milling to improve its dissolution release profile.Particle size analysis was performed using a dry dispersion method andanalyzed by laser diffraction using Sympatec equipment.

Particle size distribution was assessed using a dry dispersion methodanalyzed by laser diffraction using a Sympatec Laser Helos/KF-MagicF71000 with Rodos Dispersing Unit. The OCA sample (0.5 g sample) wastested as a dry powder. The parameters for the validated particle sizeanalysis method are described below:

Apparatus: Sympatec Laser Helos/KF-Magic F71000 with Rodos DispersingUnit, Vibri sampling unit with Sniffer rotation, Nilfisk exhaustion orequivalent.

Deionization apparatus: Sartorius or equivalent.

Measuring range: R3: 0.5/0.9 to 175 μm.

Dispersing principle: Dry.

Pressure: 1.0 bar.

Feed rate: 80%.

Feed height: 2 mm.

Sniffer rotation: 20%.

Trigger conditions: Time base: 100 ms; Start: Ka.28≧1%; Stop: 1 sc.opt≦1%.

Comilling. The use of a comil with different screen sizes was evaluated.Three comil screens were utilized: 1.14 mm, 0.61 mm, and 0.46 mm. Themilled active pharmaceutical ingredient (API) was evaluated forappearance, particle size distribution as well as process yield. Theprocess yield was difficult to determine accurately, but as expected, alarger amount of milled drug product was recovered from the largerscreen sizes. The particle size distribution of unmilled and comilledobeticholic acid is shown below in Table 1.

TABLE 1 Particle size distribution of unmilled and comilled obeticholicacid. Sample Description D₁₀ D₂₅ D₅₀ D₇₅ D₉₀ D₉₅ Unmilled API (no comil)4.8 105.1 218.6 335.7 427.6 472.6 Unmilled API (no comil) 3.3 36.4 167.7273.7 355.6 398.2 Comilled with 0.46 mm 5.7 122.9 217.5 283.0 335.1360.3 screen Comilled with 0.61 mm 4.1 102.2 263.1 351.0 410.9 447.9screen Comilled with 0.61 mm 5.5 106.6 223.2 320.8 393.8 429.8 screenComilled with 1.14 mm 7.9 73.9 239.3 340.8 412.0 452.7 screen

After the comil, the material visually appeared to have a lower particlesize and be more uniform in size when compared to unmilled (API).However, the measured particle size distribution of the material by drydispersion described above did not show a difference between thecomilled and the unmilled OCA. The PSD data demonstrate a more robustmilling technique is required to significantly reduce the particle sizeof the material.

Jet milling using Hosokawa AFG 100 jet mill

Jet milling studies were performed using a Hosokawa AFG 100 jet mill.The results showed a significant reduction in the particle sizedistribution (PSD). Jet milling was carried out with various classifierspeeds to determine the optimum set of jet mill parameters. The jet millparameters used in the Hosokawa AFG 100 jet mill are provided below:

Hosokawa AFG 100 jet mill parameters:

-   -   Pressure in the mill: −0.2˜−0.3 mm Aq.    -   Nozzle diameter/number: 1.9 Φmm× 3    -   Consumption of compressed air: 0.7 Nm3/min

Classification Parameters

-   -   Rotor rotation speed: 4000 rpm    -   Current rating of motor: 4.2 Amp    -   Current operating: 2.4 Amp    -   Rotor seal pressure: 0.1 MPa (1 bar)    -   Bearing seal pressure: 0.1 MPa (1 bar)    -   Rotor type: SUS

Powder Collector

-   -   Filter material/length/number: Gore/2 ft/4

The particle size distribution of unmilled and jet milled OCA (API) isshown below in Table 2.

TABLE 2 Particle size distribution of unmilled and jet milledobeticholic acid. Sample Description D₁₀ D₁₆ D₅₀ D₈₄ D₉₀ D₉₉ UnmilledAPI 4.8 — 218.6 — 427.6 — Jet mill, classifier speed 1.7 2.3 10.9 57.269.3 97.9 2000 rpm Jet mill, classifier speed 1.3 1.7 4.2 15.2 18.9 55.85000 rpm Jet mill, classifier speed 1.1 1.4 2.7 4.7 5.6 9.0 10000 rpmJet mill, classifier speed 1.3 1.6 3.8 17.0 21.7 36.0 4000 rpm

The results above show that jet milling at high classifier speeds (i.e.,4000 rpm, 5000 rpm and 10,000 rpm) showed a significant reduction in thePSD.

Jet milling using spiral jet mill. Jet milling studies were performedusing a spiral jet mill. The results showed a significant reduction inthe particle size distribution (PSD). Jet milling was carried out withvarious a range of parameters to determine the optimal settings. The jetmill parameters used in the spiral jet mill are provided below:

Spiral jet mill parameters controlling the final PSD are:

Feed rate: Product amount fed into the milling chamber per unit time

Pressure: Fluid pressure through the nozzle section which influences thespeed at which the particles collide

TABLE 3 Milling Parameters Used During Development at JetPharma LotBatch Nitrogen Number Size Feed Rate Pressure PSD JP1307001 10.0 kgEvaluated Evaluated X₁₀: 1 μm range: range: X₅₀: 5 μm 200-400 g/30″2.0-4.0 bar X₉₀: 20 μm Target range: Target range: 300 ± 10 g/30″ 3.0 ±0.2 bar JP1408001 5.6 kg Evaluated Evaluated X₁₀: 1 μm range: range:X₅₀: 5 μm 200-400 g/30″ 2.0-4.0 bar X₉₀: 19 μm Target range: Targetrange: 290 ± 10 g/30″ 3.2 ± 0.2 bar JP1408002 4.8 kg Evaluated EvaluatedX₁₀: 1 μm range: range: X₅₀: 4 μm 200-400 g/30″ 2.0-4.0 bar X₉₀: 14 μmTarget range: Target range: 290 ± 10 g/30″ 3.2 ± 0.2 bar JP1408003 6.3kg Evaluated Evaluated X₁₀: 1 μm range: range: X₅₀: 4 μm 200-400 g/30″2.0-4.0 bar X₉₀: 15 μm Target range: Target range: 290 ± 10 g/30″ 3.2 ±0.2 bar

The impact of jet-milling on API particle size and surface area isdetailed in Table 4-1 and Table 4-2, respectively. Surface area wastested per a BET (Brunauer, Emmett, and Teller theory). The BET methodfor analyzing surface area is based on adsorption of gas on a surface.The amount of gas adsorbed at a given pressure allows a determination ofthe surface area.

As can be observed from Table 2, the API particle size distributionafter jet-milling undergoes a dramatic shift towards much smaller, moreuniformly-sized particles within a tighter distribution, while surfacearea increases approximately 3-fold. FIG. 1 and FIG. 2 illustrate thetypical particle size distribution of unmilled and jet-milled API,respectively.

TABLE 4-1 Impact of jet-milling (micronization) on particle sizedistribution of OCA drug substance Particle Size Distribution ofUnmicronized and Micronized OCA Drug Substance OCA Example # 1 2 3Before After Before After Before After D_(v) (10) 2.6 0.7 1.8 0.6 5.30.7 D_(v) (50) 26 6.1 19 4.4 39 4.9 D_(v) (90) 162 18.8 231 17.8 22114.1 D_(v) (99) 419 30.8 509 34.6 513 25.9

TABLE 4-2 Impact of jet-milling (micronization) on surface area of OCAdrug substance Surface Area of Unmicronized and Micronized OCA DrugSubstance OCA Example # 1 2 3 Before After Before After Before AfterSurface Area 1557 3178 1854 3848 809 3412 (m²/kg)

Example 2 Improved Manufacturing Process of Obeticholic Acid (OCA)Tablets

The manufacturing process of 5 mg and 10 mg obeticholic acid (OCA)tablets uses dry granulation by roller compaction followed by tabletcompression and coating. The process steps used to manufacture OCAtablets include: pre-blending; dry granulation, final blending,compression, coating, and packaging. The equipment used to manufactureOCA tablets are shown in Table 5.

TABLE 5 Equipment Used to Manufacture OCA Tablets Process Step EquipmentSieving 0.5 mm and 1.0 mm aperture sieve Pre-blending Drum and Binblender, appropriately sized drum and bin Roller Roller compactor,Alexanderwerk PP150 (or WP120) compaction or equivalent fitted withupper and lower mill screens Final Bin blender, appropriately sized binblending Compression Rotary tablet press, Kilian T300 or equivalentCoating Perforated pan coater, Manesty Accelacota 150 or equivalent48-inch coating pan

Microcrystalline cellulose was added to the intra-granular portion ofthe tablet mixture which produced tablets of moderate hardness.Modification to the manufacturing process to add microcrystallinecellulose to both the intra-granular and extra-granular portions of thetablet for both the 5 mg and 10 mg tablet generated more robust tablets(harder tablets). The compression challenges observed were overcome byredistributing a portion of microcrystalline cellulose in the 5 mg and10 mg OCA formulation blends. This change in the manufacturing processimpacted the quality attributes, specifically the dissolution profile,of the OCA tablets.

OCA drug substance and excipients were added in specific quantities andorder during pre- and final blending. Prior to manufacture, thematerials were dispensed in the appropriate portions as shown in Table6. Microcrystalline cellulose (MCC) and sodium starch glycolate (SSG)were sieved with a 1.0 mm aperture sieve before use. Magnesium stearatewas sieved using a 0.5 mm aperture sieve immediately before use.

TABLE 6 Material Dispensing Summary for OCA Tablets Quantity forQuantity for Quantity for 5 mg OCA 10 mg OCA 25 mg OCA Tablet TabletTablet Formulation Formulation Formulation Component (kg) (kg) (kg)Intra-granular (Pre Blending) OCA drug substance 2.5^(a) 5.0^(a)12.5^(a) MCC-for-Premix 7.5 10.0 25.0 MCC-for-Rinse 7.5 10.0 12.5 MCC-125.5^(a) 33.0^(a) 41.0^(a) SSG-1 4.0 4.0 4.0 Silicon dioxide-1 — — 1.0Magnesium stearate-1 0.5 0.5 0.5 Extra-granular (Final Blending) MCC-250.0^(b) 35.0^(b) — SSG-2 2.0^(b) 2.0^(b) 2.0^(b) Silicon dioxide-2 — —1.0^(b) Magnesium stearate-2 0.5^(b) 0.5^(b) 0.5^(b) Coating Opadry ® IIYellow 6.0^(c) 6.0^(c) 6.0^(c) 85F32351 Purified water^(d) 24.0 24.024.0 Total 104.0 104.0 104.0 MCC = Microcrystalline cellulose; SSG =Sodium starch glycolate; ^(a)OCA drug substance amount assumes the drugsubstance content is 100%; actual amount added is adjusted for based onthe potency of the drug substance lot used; the amount ofmicrocrystalline cellulose is correspondingly decreased. ^(b)The amountsof extra-granular excipients are adjusted based on the yield of theprocess through roller compaction. The dispensing summary presentedassumes a 100% yield through roller compaction. ^(c)The amount ofcoating material prepared during the process is 150% of target. Excesscoating material is discarded. ^(d)Water is removed during processing.

Preblending Process. To an appropriately sized blender drum was addedOCA and a microcrystalline cellulose (MCC) for premix (MCC-for-Premix: aportion of the total MCC added to the tablet formulation) to produce OCApremix. The resulting mixture was blended 90 to 120 revolutions(approximately for 3 minutes at a blender speed of about 30 rpm) anddischarged. For the 5 mg tablets, OCA was pre-mixed with approximately 3parts MCC (to 1 part OCA). For the 10 mg tablets, OCA was pre-mixed withapproximately 2 parts MCC (to 1 part OCA).

After unloading the API/MCC premix (OCA premix) from the drum, the drumwas rinsed with a further portion of MCC (MCC-for-Rinse: same amount asused for the premix), to recover any API retained on the drum surfacesto provide the MCC-rinse portion. A blend time of 3 minutes (i.e., about90 to 120 revolutions) was used for this rinse process, i.e., MCC-rinseprocess. The API/MCC premix and MCC drum rinse (MCC-rinse portion) werepassed through a 1.0 mm aperture sieve on addition to the larger drumused for the Pre-RC (roller compaction) blending process (i.e., 150liter drum for 5 mg tablets and 70 liter drum for 10 mg tablets). Thesieve removed any soft agglomerates of OCA, and ensured good blenduniformity was achieved before roller compaction.

An appropriately sized bin was then charged with the followingcomponents: approximately ¼ (one-fourth) of MCC-1, ½ (half) of OCAPremix, MCC drum rinse (MCC Rinse), ½ of OCA Premix, and ¼ of MCC-1 inthe order specified. The resulting mixture was then blended for 300 to360 revolutions (about 20 minutes for 5 mg tablets, about 10 minutes for10 mg tablets) in a Pharmatech MB400 drum blender or a Tumblemix drumblender or V-blender. The SSG-1 and the remaining ½ of MCC-1 was addedto the bin and the mixture was then blended for 300 to 360 revolutions(about 10 to 20 minutes). Magnesium stearate-1 was then added to the binvia a 0.5 mm aperture sieve and the mixture was blended for 70 to 90revolutions (about 3 minutes). For the 25 mg tablet, silicon dioxide wasadded via a 0.5 mm aperture sieve together with SSG-1 and the remaining½ of MCC-1 to the bin and the mixture was then blended for 300 to 360revolutions (about 10 to 20 minutes). The blender revolutions for thevarious preblending steps provide homogeneity of the pre-blendformulation.

Dry granulation. The pre-blend was transferred from the bin blender tothe roller compactor hopper. The pre-blend was roller compacted toprovide flakes which were milled into granules through an in-line dualscreen milling system. The granules were then collected in a suitablecontainer. Roller compaction parameters used in the commercialproduction are shown in Table 7. This process provided the rollercompacted active granules (intra-granular portion) for use in the finalblending step. Roll pressure (compaction force), roll gap, and screensize (lower mill) are meaningful process parameters in the rollercompaction process. The roll pressure, roll gap, and screen sizeprovided granules with consistent physical characteristics andparticle-size distribution.

TABLE 7 Roller Compactor Settings Used for Commercial ProductionAttribute Setting Roll pressure (bar) 40 to 48 Roll gap (mm) 2.5 to 4.0Upper mill screen size (mm) 2.0 Lower mill screen size (mm) 0.8

Final Blending. The final blending of the OCA tablet formulation wasperformed in 2 steps. First, an appropriately sized bin was charged withthe roller-compacted active granules (intra-granular portion),extra-granular sodium starch glycolate-2 (SSG-2) and extra-granularMCC-2, and the resulting mixture was blended for 450 to 540 revolutions.For the 25 mg tablet, silicon dioxide was added via a 0.5 aperture sievetogether with SSG-2 and extra-granular MCC-2. Magnesium stearate-2 wasthen added to the bin and the mixture was blended for 70 to 90revolutions. Blender revolution is a meaningful process parameter in thefinal blending process providing a final blend with acceptablehomogeneity.

Compression Process. The final blend prepared in the blending processwas used to supply the rotary tablet press fitted with the appropriateOCA tablet tooling. OCA tablet tooling is specific to the tabletstrength. During equipment start-up, the tablet press was set up byadjusting compression parameters to produce tablets that meet thein-process control targets for tablet weight, hardness, thickness, andfriability. Tablet press speed (about 70 rpm) and feeder speed (about 30rpm to about 40 rpm) were set to achieve satisfactory tablet weightvariation. The tablet press depth of fill was set to achieve the targettablet weight. The main compression pressure (rollers) was set toachieve the target hardness and thickness (compression force of about 8kN). A small amount of pre-compression force (about 0.5 kN) was appliedbefore the main compression to expel air from the blend to ensuresatisfactory tablet friability. Adjustments were made throughout thecompression operation to continuously meet the in-process controltargets. After the tablets were ejected from the press, they were passedthrough a tablet deduster and metal detector prior to collection intablet containers.

In-process control testing for appearance, tablet weight, hardness,thickness, friability, and disintegration time is conducted at specificinternals throughout the tablet compression process and are provided inTable 8. Press speed and compression are meaningful process parametersin the tablet compression process. The specified press speed providedtablets with the target tablet weight. Compression, including both pre-and main compression, provided tablets that met the tablet hardness,thickness and firability limits. In addition, the provided tabletsshowed fast disintegration time.

TABLE 8 In-Process Tests for Compression Step 5 mg OCA 10 mg OCA 25 mgOCA In-process Tablets Tablet Tablet Test Acceptance Criteria AppearanceWhite, round White, White, oval tablets with triangular tablets with 5debossed on tablets with 25 debossed on one side and 10 debossed on oneside and INT on the one side and INT on the other side INT on the otherside other side Weight of 20 3.92 g to 4.08 g (Target 4.00 g) tabletsIndividual 200 mg, NMT 2 individual tablets deviate from mean weight ofby more than 7.5% and none by more than 15% 20 tablets Hardness 7 kP to13 kP 8 kP to 14 kP 9 kP to 15 kP (mean) (target 10 kP) (target 11 kP)(target 12 kP) Thickness 3.5 mm to 4.0 mm to 4.3 mm to (mean) 4.1 mm 4.6mm 4.9 mm (target: 3.8 mm) (target: 4.3 mm) (target: 4.6 mm) FriabilityNMT 0.5% (6.5 g/100 rotations) Disintegra- NMT 2 min tion time (6tablets) NMT = not more than

Tablet Coating. The 5 mg and 10 mg OCA tablets were coated with anon-functional immediate release coating material. Tablet cores werecoated with Opadry® II coating material using a perforated pan coaterand a 48-inch pan. A 20% w/w coating solution was prepared by mixingOpadry® II with purified water. An excess of coating solution wasprepared to ensure sufficient coating material is available for thecoating process.

The tablet cores were loaded into the pan of the perforated pan coater(i.e., O'Hara Labcoat MX coating machine and 1×Schlick Model 930/7-1 S35with 1.2 mm nozzle spray gun) and the coating process was initiated. Thepan rotation speed (about 12 rpm) was monitored and maintained in theappropriate range to ensure the tablet cores flowed consistentlythroughout the coating process. Pan speed is a meaningful processparameter, as this can affect tablet appearance (too high a pan speedcan damage the tablets). Tablet bed temperature is a meaningful processparameter, as this can affect tablet water content and protects thetablets from over-wetting (which causes tablet appearance defects).Exhaust air temperature is linked to tablet bed temperature and is ameaningful process parameter if tablet bed temperature is not recorded.

The supply air temperature of about 60 to 72° C. and an exhaust airtemperature of about 45 to 55° C. was used to maintain tablet bedtemperature at about 45 to 48° C. Supply and exhaust air temperatureswere monitored throughout the coating step to maintain the bedtemperature range of about 45 to 48° C. After the desired 4% weight gainwas achieved, the pan speed and supply air temperature were reduced (toabout 4 rpm and 45° C.) to ensure dry tablets. The heater was thenturned off and tablets were further cooled while jogging the pan. Tabletweight gain (target 4% gain) and appearance were checked periodicallyduring the tablet coating process as in-process controls. The in-processtests conducted during the coating process are shown below in Table 9.

TABLE 9 In-Process Tests for Coating Process 5 mg OCA 10 mg OCA 25 mgOCA In-process Tablets Tablets Tablets Test Acceptance CriteriaAppearance Off-white to Off-white to Off-white to yellow, round yellow,yellow, oval tablets with triangular tablets with 5 debossed on tabletswith 25 debossed on one side and 10 debossed on one side and INT on theone side and INT on the other side INT on the other side other sideTablet 3.0% to 5.0% 3.0% to 5.0% 3.0% to 5.0% weight gain

Packaging. Tablets were packaged in the commercial primary packagingconfiguration using a standard automated bottling operation. The primarypackaging configuration utilized a white high-density polyethylenebottle (40 cc) and child resistant cap with an induction seal. Thecommercial bottle will contain 30 OCA tablets. Tablet quantity,induction seal, cap torque, print quality, and appearance controltesting was conducted at specific intervals throughout the packagingprocess. Induction sealing is a meaningful process parameter in thepackaging process providing a completely sealed bottle. The in-processtesting parameters for the packaging process is provided in Table 10below.

TABLE 10 In-Process Tests for Packaging Process In-process TestAcceptance Criteria Tablet quantity Correct tablet fill quantity (30count) Induction seal integrity Totally sealed bottle Cap torque test 15lb/in² to 25 lb/in² Print quality Print is present and correctAppearance (AQL inspection) Satisfactory AQL = Acceptable quality limit

Example 3 Dissolution Testing of Obeticholic Acid Film-Coated Tablets

Unmilled 5 mg tablet and 10 mg tablet formulations of OCA were observedto release the drug slowly. The formulation of the 5 mg and 10 mgtablets are shown below in Table 11.

TABLE 11 5 mg, 10 mg, and 25 mg film-coated tablets formulationsmg/tablet Material 5 mg 10 mg 25 mg Intragranular OCA Drug Substance^(a) 5.0 10.0 25.0 Microcrystalline Cellulose ^(a) 81.0 106.0 157.0Sodium Starch Glycolate 8.0 8.0 8.0 Colloidal Silicon Dioxide — — 2.0Magnesium Stearate 1.0 1.0 1.0 Granule Mass 95.0 125.0 193.0 Ratio ofMicrocrystalline about about about Cellulose to OCA 16:1 11:1 6:1Extragranular Microcrystalline Cellulose 100.0 70.0 — Sodium StarchGlycolate 4.0 4.0 4.0 Colloidal Silicon Dioxide — — 2.0 MagnesiumStearate 1.0 1.0 1.0 Final Blend/Tablet Core 200.0 200.0 200.0 TabletCoating Opadry II Coating Material 8.0 8.0 8.0 Coated Tablet 208.0 208.0208.0 ^(a) OCA quantity presented assumes drug substance is anhydrousand 100% pure; actual amount is adjusted based on potency of the drugsubstance lot used, and amount of microcrystalline cellulose iscorrespondingly decreased.

Upon testing, the tablets containing unmilled OCA demonstrated a slowdissolution release profile. For the dissolution method, both RI andCorona detectors were initially evaluated for analysis of thedissolution media. Considering the need to quantify OCA (INT-747) atlevels as low as 10% of a 5 mg strength tablet dissolved in thedissolution media (1 μg/mL), the Corona CAD detector was chosen for thedissolution tests because it has a better sensitivity to OCA than the RIdetector.

Tablet dissolution for both the 5 mg and 10 mg tablets was conducted in900 mL of 50 mM Disodium Hydrogen Phosphate Buffer (Na₂HPO₄), pH 6.8 at37° C. using USP II paddle apparatus at a paddle speed of 75 rpm.Samples were assayed undiluted by filtering through a 0.2 μm PVDFsyringe filter using a gradient RP-HPLC method with CAD detection. Thismethod utilized an Agilent Zorbax SB-C18 4.6 mm×150 mm, 3.5 μm HPLCcolumn. A 50 μL sample was separated by a 20 minute gradient program, ata temperature of 40° C. and a flow rate of 1.5 mL per minute. Two mobilephases were used in the program; one consisted of a degassed AcidifiedWater pH 3.0/Acetonitrile (45:55) mixture and the other degassedAcetonitrile. The OCA drug substance eluted with an approximateretention time of 10 minutes.

The dissolution methodology is summarized below in Table 12.

TABLE 12 Parameters for the obeticholic acid 5 mg and 10 mg tabletdissolution method. Parameter Value Apparatus USP Apparatus II (paddles)Dissolution Media 50 mM sodium phosphate dibasic buffer, pH 6.8Dissolution Volume 900 mL Rotation Speed 75 rpm Temperature 37° C. ±0.5° C. Sample Volume 10 mL with medium replacement Sample Pull Times10, 15, 30, 45, 60 minutes Sample Analysis HPLC/Corona CADAbbreviations: HPLC = high performance liquid chromatography; rpm =revolutions per minute; USP = United States Pharmacopeia; CAD = chargedaerosol detector

Obeticholic acid was comilled with a 0.61 mm screen or jet-milled asdescribed above to reduce the particle size of the material. Jet-milling(i.e., micronization) resulted in material that had a smaller, moreuniform particle size and increased surface area, leading to faster drugrelease from tablets containing jet-milled OCA. The dissolution releaserate of tablets containing comilled and jet-milled OCA is shown below inTable 13.

TABLE 13 Dissolution release rates of comilled and jet-milled OCA 5 mgtablets 10 mg tablets 5 mg tablets containing containing containingDissolution comilled OCA comilled OCA Jet-milled OCA time DissolutionDissolution Dissolution (min) rate (%) rate (%) rate (%) 15 42 51 83 3057 66 89 45 68 79 91 60 77 85 94 75 89 92 95

Table 13 shows that reduction in particle size of the OCA drug productimproves elution properties.

As shown in FIG. 3 and FIG. 4, the particle size distribution of the OCAimpacted the drug dissolution rate, even in media where OCA is freelysoluble (pH 6.8). It is therefore possible that differences in particlesize could impact OCA bioavailability if dissolution becomesrate-limiting for absorption. For this reason, the particle sizedistribution of the active is considered a critical process parameter.

The dissolution profiles of 10 mg tablets containing either unmilled (abatch of unmilled OCA with smaller particle size; D₅₀>about 100 μM),unmilled/agglomerated, or jet-milled OCA is compared in FIG. 3.

Drug release was compared for 5 mg tablets containing unmilled(agglomerated) and jet-milled OCA. The difference in release profileswas more dramatic for the 5 mg tablets than the 10 mg tablets. This islikely due to coning effects in the smaller dissolution volume of 500 mLwhich may have contributed to the slower/incomplete dissolution due tothe non-favorable hydrodynamics in the test vessel. The dissolutionprofiles of 5 mg tablets containing either unmilled/agglomerated, orjet-milled OCA is compared in FIG. 4.

Example 4 Content Uniformity Testing of Obeticholic Acid Tablets

The content uniformity of 5 mg and 10 mg tablets containing comilled OCAand jet-milled OCA was evaluated by RP-HPLC. The results are shown belowin Table 14.

TABLE 14 Content uniformity of 5 mg and 10 mg tablets of unmilled,comilled and jet-milled OCA 5 mg tablets 10 mg tablets 5 mg tabletscontaining containing containing comilled OCA comilled OCA jet-milledOCA Content 104 (AV = 18, 104 (AV = 14, 105.2 (AV = 8, Uniformity89.0%-110.6%) 97.4%-111.5%) 101.4%-109.2%) (%)

The results in Table 14 show the content uniformity data for tabletscontaining comilled and jet-milled OCA. Tablets containing comilled OCAshowed a higher variability in content uniformity. The smaller particlesize of the jet-milled material provides better content uniformity ofthe OCA tablets.

Example 5 Stability Studies of 5 mg and 25 mg Obeticholic Acid Tablets

The stability of 5 mg and 25 mg tablets were tested in acceleratedstability studies. The stability test was conducted at 40° C. and 75relative humidity (RH) for 6 months. The formulation of the 5 mg and 25mg tablets are shown above in Table 11.

5 mg and 25 mg OCA tablets were placed on stability at the 40° C./75% RHstorage conditions. Samples stored at the accelerated condition werepulled from storage at 1, 2, 3, and 6 months for assessment ofstability. The tests performed for stability evaluations includeappearance, assay for OCA by HPLC, and related substances by HPLCCorona.

Obeticholic acid and formulations of obeticholic acid were tested forstability. An unknown impurity at relative retention time (RRT) 1.75 wasobserved during stability studies of the tablets containing differentbatches of the 5 mg and 25 mg tablet formulation. The stability testusing uncoated tablets showed an increase of a new impurity at about0.05% with the test conducted at 25° C., 60% RH for 4 weeks, and about0.2% with the test conducted at 40° C., 75% RH for 4 weeks. A study wasconducted to identify the structure of the impurity, clarify the originfor the generation of the impurity, and adopt measures to ensure thatquality was not compromised during storage of the tablet. The structureof OCA and the identified structure of the impurity are respectivelyshown below:

An analysis was conducted with LC/HRMS using LTQ-Orbitrap Discovery. TheLC/HRMS Test conditions used are outlined in Table 15 below:

TABLE 15 LC/HRMS conditions for identifying impurities found in OCAafter stability testing Equipment: [HPLC] Shimadzu prominence (LC-20Aseries) [MS] Thermo Fisher Scientific LTQ Orbitrap Discovery IonizationESI (negative and positive mode) method: HPLC [Column] Phenomenex,Kinetex C-18, 2.6 μm, conditions: 4.6 mm I.D. × 100 mm [Mobile A: AcOHaqueous solution*¹ containing phase] 15% MeOH B: MeCN containing 15%MeOH Gradient conditions. Time (min.) B (%).  0.0 → 25.0 40 → 65 25.0 →35.0 65 → 95 35.0 → 50.0 95 50.0 → 50.1 95 → 40 50.1 → 60.0 40 60.1 stop[Measurement 60 min time] [Detection] Total Ion Current Chromatogram(TICC) [Flow rate] 1.0 mL/min. [Column Approximately 40° C. temperature][Sample drug Mobile phase B product solvent] [Injection] 5 μl Sample*²OCA drug product (product stored for 4 weeks at 60° C.) solution (OCAconcentration 500 μg/mL) *³ Drug product placebo solution (prepared inthe same way as (1)) Impurity 1-5 and OCA mixed solution (5 μg/mL each)OCA powder (5000 rpm) OCA unground product OCA drug product (stored at50° C., 85% RH for 4 weeks) solution

Based on the results, it was determined that the impurity is an ethylester of obeticholic acid (OCA). Subsequently, an authentic sample ofthe ethyl ester was synthesized by dissolving obeticholic acid inethanol, adding concentrated sulfuric acid and heating the mixture. Theretention time and mass spectrometry of the authentic sample matchedthose of the impurity and thus the structure of the impurity wasconfirmed as an ethyl ester of obeticholic acid (FIG. 7A and FIG. 7B).Comparison of the retention time and the mass spectrum of the ethy esterimpurity and authentic sample is shown in FIG. 7A and FIG. 7B.

Bottom row: TICC of ethyl ester (positive mode)

The structure of the ethyl ester impurity (shown above) was determinedthrough mass spectrometry analysis combined with analysis of OCAfragmentation, and was confirmed by mass spectrometry analysis ofsynthesized OCA ethyl ester (the above authentic sample having the sameretention time as the ethyl ester impurity).

Since the ethyl ester impurity can be formed in the presence of ethanol,the formulation was examined to determine if any excipient could be apossible source of the ethanol. It was found that sodium starchglycolate from two different manufacturers, sodium starch glycolate(Glycolys®) from Roquette Pharma containing no more than 6% ethanol andsodium starch glycolate (Explotab®) from JRS Pharma containing no morethan 3% ethanol, were used to make the tablet formulations. A comparisonof accelerated stability data at 40° C./75% RH of batches are shownbelow in Table 16.

TABLE 16 OCA Ethyl Ester Impurity (RRT 1.75) Content in Accelerated (40°C./75% RH) Stability Studies Lot Number (Manufacturer) Time 0 1 Month 3Months 6 Months DNSY, 5 mg ND ND ND ND Patheon (Explotab ®) DNSZ, 25 mgND ND ND ND Patheon (Explotab ®) PDS0048-03, 5 mg ND NT 0.35% 0.44%Piramal (Glycolys ®) PDS0048-10, 25 mg ND NT 0.17% 0.25% Piramal(Glycolys ®) ND = Not detected; NT = Not tested

The results in Table 16 show that the ethyl ester impurity is notobserved after 6 months in samples containing low ethanol sodium starchglycolate (i.e., Explotab®). However, the ethyl ester impurity insamples containing high ethanol sodium starch glycolate (i.e.,Glycolys®) was observed as early as three months into the stabilitystudy. This data indicates that the ethanol content of the sodium starchglycolate is critical to the stability of the OCA formulation.

Stability Testing of Film Coated Tablets. Furthermore, in the filmcoated tablet stability test an increase in a specific impurity wasconfirmed at a rate of approximately 0.09% with the test conducted at40° C., 75% RH for 4 weeks. Given that the generation of this impurityonly occurred in film coated tablets, it was surmised that the impuritywas a reactant with a film coating component. Also, based on thestructure of ethyl ester impurity it is known that the carboxylic acidof OCA reacted easily with alcohol. Of the film coating components, itwas possible that 2 components, polyvinyl alcohol (PVA) and polyethyleneglycol (PEG) 4000 could be the cause of the impurity.

Subsequently, when a blending combination change test was conducted thespecific impurity was generated and it was discovered that PEG4000 wasthe cause. Therefore, it was estimated that the structure of thisimpurity was an ester produced by a reaction between a PEG4000 hydroxylgroup and the OCA carboxylic acid. The structure of OCA and PEG esterimpurity are shown below:

High resolution mass spectrometry (HRMS) was conducted to confirm thestructure. The mean molecular weight of PEG ester impurity was expectedto exceed 4000. micrOTOF-QII (Bruker Daltonics) was used to measure highmolecular weight compounds. When measured with the APCI technique inpositive mode, an m/z was obtained that supported the structure of PEGester impurity shown above. (FIGS. 8A, 8B, and 8C). Enlargement of themass spectrum of a sample containing the specific impurity showed peakspacing characteristic of PEG (FIG. 9).

The LC/HRMS Test conditions used are outlined in Table 17 below:

TABLE 17 LC/HRMS test conditions for the identification of the impurityfound in film coated OCA tablets after stability testing. Equipment:[HPLC] Agilent 1200 [MS] micrOTOF-QII (Bruker Daltonics) Ionization APCIpositive mode method: HPLC [Column] Phenomenex, Kinetex C-18, 2.6 μm,conditions: 4.6 mm I.D. × 100 mm [Mobile A: AcOH aqueous solution*²phase] containing 15% MeOH B: MeCN containing 15% MeOH Gradientconditions. Time (min.) B (%).  0.0 → 25.0 40 → 65 25.0 → 35.0 65 → 9535.0 → 50.0 95 50.0 → 50.1 95 → 40 50.1 → 60.0 40 60.1 stop.[Measurement 60 min time] [Detection] Total Ion Current Chromatogram(TICC) [Flow rate] 1.0 mL/min. [Column Approximately 40° C. temperature][Sample drug Mobile phase B product solvent] [Injection] 5 μl Sample OCAfilm coated tablet (product stored for 4 weeks at 60° C.) extractsolution*³ *²pH 3.0 *³The 500 μl sample prepared was concentrated todryness under a stream of nitrogen, dissolved in 50 μl of mobile phase Band used as the sample (OCA concentration: 5 mg/mL).

The extract from the film coated tablets was measured using the APCItechnique in positive mode. Analysis of the retention time, the massspectra, and the m/z value confirmed the structure of PEG ester impurity(shown above and in FIGS. 8A, 8B, and 8C).

Example 6 Solubility Studies of OCA in Various Buffers and BiologicalMedia

Solubility Studies of OCA in Various Buffers. A study was performed toscreen different media of various pH over the pH range 1.2-10.0,incorporating the physiological pH range (1.2-6.8) for immediate releasetablets. The solubility of OCA was measured at 37° C. in various buffersfrom pH 1.2 to 10.0. The equilibrium solubility results for OCA invarious aqueous buffer solutions are presented in Table 18 below.

TABLE 18 Equilibrium solubility and recovery for OCA at 37° C. invarious buffers from pH 1.2 to 10.0 Solubility % USP Solubility pH,Media (Buffer) (mg/mL) Recovery Rating pH 1.2 Hydrochloric acid N/A <1Practically insoluble pH 2.0 Hydrochloric acid N/A <1 Practicallyinsoluble pH 3.0 Acid Phthalate N/A <1 Practically insoluble pH 4.1Acetate 0.003 <1 Slightly soluble pH 5.1 Acetate 0.023  5 Sparinglysoluble pH 6.0 Phosphate 0.050 10 Soluble pH 6.8 Phosphate^(a) 0.220 94Freely soluble pH 7.0 Phosphate 0.462 92 Freely soluble pH 8.0 Phosphate0.486 97 Freely soluble pH 9.0 Alkaline Borate 0.462  92^(b) Freelysoluble pH 10.0 Alkaline Borate 0.056  11^(b) Soluble ^(a)Dissolutionmedia (50 mM sodium phosphate dibasic buffer, pH 6.8) ^(b)Basicdecomposition of drug substance suspected.

OCA is a weak acid (pK_(a)=4.82) and exhibits a pH-solubility profileconsistent with that of a weak acid. As expected, the solubility of thefree acid form is highest when deprotonated and lowest when protonated.

OCA drug substance was observed to precipitate out of solution in thoseacidic buffers in the pH range 1.2 to 3.0. Solutions at pH 4.1 to 6.0also had some precipitation resulting in a cloudy solution. Solutions atpH 6.8 to 10 produced clear solutions. The recovery of OCA steadilydiminishes at pH higher than 8.0, indicating basic decomposition of thedrug substance.

The nominal concentration for dissolved 5 mg and 10 mg tablets in thetypical dissolution volume of 900 mL is approximately 0.006 & 0.01mg/mL, respectively. Above pH 6.8 the solubility is well above 0.01mg/mL, the minimum concentration required to dissolve a 5 mg or 10 mgtablet in 900 mL of dissolution medium (i.e., sink conditions).

As demonstrated in FIG. 5, solubility of OCA increases as a function ofincreasing pH, plateauing just above approximately pH 7. The dramaticincrease in solubility observed between approximately pH 4 and pH 7indicates that this pH region is less-than-ideal for use in thedissolution media. However, given that OCA is freely soluble at pH 6.8and that this pH is physiologically relevant to the site of absorption,it was selected for use in diligent pursuit of a discriminating andrelevant dissolution method.

Solubility Studies of OCA in Biological Media. A solubility study wasperformed in physiologically relevant dissolution media at 37° C. and pHof 1.2, 4.5, and 6.8 along with fasted state simulated gastric fluid(FaSSGF, pH 1.2), fed state simulated intestinal fluid (FeSSIF, pH 5.0)and fasted state simulated intestinal fluid (FaSSIF, pH 6.5). Thesolubility results for OCA in physiologically relevant buffers arepresented in Table 19.

TABLE 19 Solubility of OCA in biologically relevant media at 37° C.Solubility pH (Medium) (mg/mL) USP Solubility Rating 1.2 (0.1N HCl) <LOQPractically insoluble 1.2 (FaSSGF)^(a) <LOQ Practically insoluble 4.5<LOQ Practically insoluble 5.0 (FeSSIF)^(b) 0.82 Freely soluble 6.5(FaSSIF)^(c) 0.64 Freely soluble 6.8^(d) 0.22 Freely soluble 6.8 withsurfactant^(e) 0.59 Freely soluble ^(a)FaSSGF is de-ionized watercontaining sodium taurocholate (80 μM) and NaCl (34.2 mM), pH 1.6.^(b)FeSSIF is de-ionized water containing sodium taurocholate (15 mM)and lecithin (3.75 mM) with an osmolarity of 635 ± 10 mOsmol, pH 5.0.^(c)FaSSIF is de-ionized water containing sodium taurocholate (3 mM) andlecithin (0.75 mM) with an osmolarity of 270 ± 10 mOsmol, pH 6.5.^(d)Proposed dissolution medium; 0.5 mM sodium phosphate dibasic, pH6.8. ^(e)Surfactant is polysorbate 80 (Tween 80 ®) Abbreviation: USP =United States Pharmacopeia

As shown in Table 19 and FIG. 6, from a Biopharmaceutical ClassificationSystem (BCS) perspective, OCA is poorly soluble below pH 4.5 and highlysoluble above pH 5.0 in biologically relevant media. This providesfurther support and justification for selecting pH 6.8 phosphate bufferas the dissolution medium. A 35-fold increase in OCA solubility isevident at pH 5.0 in the presence of the taurocholate bile acid andlecithin emulsifier vs. pH 5.1 acetate buffer alone. This is likely dueto the formation of highly soluble micelles in the presence of theamphipathic surfactant lecithin. One would expect similar solubilityenhancement in vivo, as taurocholic acid and lecithin are typicallypresent in the gastric and intestinal milieu.

Example 7

This example describes a study of two doses of OCA (10 mg and 50 mg) vs.placebo for a period of 12 weeks (85 days). The study was completed by48 patients and PK data are available for 34 patients. All patientsreturned to the study site for 4 visits (Day 15, Day 29, Day 57, and Day85) for evaluations of efficacy, safety, tolerability, and compliancewith investigational product.

Key Inclusion criteria:

-   -   Age>18 years,    -   Both male and female had to use one effective method of        contraception,    -   Proven or likely PBC demonstrated by patient presenting with at        least 2 of the 3 diagnostic criteria    -   History of increased ALP    -   Positive AMA    -   Liver biopsy consistent with PBC    -   Screening ALP value between 1.5 and 10×ULN.

Key Exclusion Criteria

-   -   1. The following drugs were contraindicated: ursodeoxycholic        acid (UDCA), colchicine, methotrexate, azathioprine, or systemic        corticosteroids    -   2. Conjugated bilirubin>2×ULN; ALT or AST>5×ULN and serum        creatinine>133 μmol/L (1.5 mg/dL)    -   3. History or presence of hepatic decompensation    -   4. History of presence of concomitant liver diseases such as        Hepatitis B or C; HIV; primary sclerosing cholangitis, alcoholic        liver disease, definite autoimmune liver disease or biopsy        proven nonalcoholic steatohepatitis (NASH).

The percent change (%) in serum ALP from Baseline to End of Study (EOS)was monitored. The baseline value was the mean of the pretreatmentscreening and day 0 evaluations. The EOS value was Day 85/ET or the lastobserved ALP value on treatment.

Absolute changes in serum ALP levels were monitored from Baseline to Day15, Day 29, Day 57, Day 85/ET and Follow-Up (Day 99). The percentage ofpatients was calculated who met the definition of PBC responder criteriaapplying the Paris I, Toronto I, Toronto II, Toronto III, Toronto IV,Mayo II, and Barcelona disease prognostic risk criteria at Day 85/ET.Each patient was tested for absolute and percent change in serumaspartate aminotransferase (AST), alanine aminotransferase (ALT),gamma-glutamyl transferase (GGT), and conjugated (direct) bilirubinvalues from Baseline to Day 15, Day 29, Day 57, Day 85/ET and Follow-Up(Day 99). Efficacy results are shown in Table 20 below.

TABLE 20 Percent Change in ALP from Baseline - ITT population. PercentPlacebo OCA 10 mg OCA 50 mg Change (n = 23) (n = 20) (n = 16) Mean (SD)0.4 (15.3) −44.5 (24.4) −37.6 (21.0) Median −0.8 −53.9 −37.2p-value^(a,b) NA <0.0001 <0.0001

Reductions in GGT and ALT and AST. GGT levels decreased, relative toplacebo, at all-time points from day 15 to Day 85/ET in both the OCA 10mg and OCA 50 mg groups. In the ITT Population, the mean (SD) GGT levelsdecreased from 653 (370) U/L at baseline to 184 (203) U/L at Day 85/ETin the OCA 10 mg group, and from 455 (418) U/L at baseline to 202 (300)U/L at day 85/ET in the OCA 50 mg group. Placebo GGT levels were 466(321) U/L at Baseline and 502 (383) U/L at Day 85/ET.

ALT levels decreased, relative to placebo, from baseline to Day 85/ET inboth OCA 10 mg and OCA 50 mg groups. The mean (SD) ALT levels decreasedfrom 86 (44) U/L at baseline to 54 (41) U/L at Day 85/ET in the OCA 10mg group, and similarly decreased from 71 (38) U/L at baseline to 49(29) U/L at Day 85/ET in the OCA 50 mg group. There was no change in thelevels of ALT in the placebo group from baseline to Day 85/ET.

The mean (SD) AST levels at Day 85/ET were 54 (40) U/L and 56 (28) U/Lin OCA 10 mg and OCA 50 mg groups compared to baseline levels of 67 (33)U/L and 66 (29) U/L, respectively. There was no change in the levels ofAST in the placebo group from Baseline to Day 85/ET.

Changes in serum lipids were observed across all treatment groupsincluding placebo, but the magnitude of HDL-C change was greater in theOCA treatment groups. Mean HDL-C levels decreased from 1.73 (0.45)mmol/L at baseline to 1.57 (0.46) mmol/L at the end of treatment (ET) inthe OCA 10 mg arm. In the OCA 50 mg arm, the mean (SD) HDL-C decreasedfrom 1.95 (0.55) mmol/L at baseline to 1.86 (0.56) mmol/L at ET. In theplacebo arm the mean HDL-C decreased from 1.84 (0.52) mmol/L at baselineto 1.70 (0.44) mmol/L at ET. The effect of HDL-C lowering is not asprominent in the OCA 50 mg treatment group, perhaps due to a 44% dropoutrate which occurred early in treatment (<1 month). At Day 85/ET, a meanchange in LDL-C of −0.08 (0.43) mmol/L was observed in the placebo groupcompared to mean changes of +0.10 (0.58) mmol/L and +0.23 (0.52) mmol/Lin the OCA 10 mg and OCA 50 mg groups, respectively.

Patients with early stage PBC demonstrated ALP reductions with OCA 10 mgand 50 mg monotherapy, which were greater than placebo (on averageapproximately 40% for each OCA dose vs. minimal change in placebo). Theadverse events reported were consistent with the known safety profile ofthe drug, with pruritus and headache being the most frequent AEsreported. Fatigue was reported infrequently.

TABLE 21 ALP Levels (U/L) at Baseline and Day 85/ET: ITT Population (N =59). Placebo OCA 10 mg OCA 50 mg (n = 23) (n = 20) (n = 16) BaselineMean (SD) 408.4 (223.0) 461.6 (298.7) 431.1 (177.2) Median 320.5 366.3379.0 Day 85/ET Mean (SD) 420.1 (253.5) 228.1 (117.0) 269.8 (158.9)Median 288.0   196.5 197.5 Change from 11.7 (63.0) −233.5 (212.3) −161.3(129.7) Baseline to Day 85/ET, Mean (SD)

Example 8

This example describes a study conducted using an international,multi-center, randomized, double-blind, placebo-controlled, multi-dose,parallel group to determine efficacy and safety of obeticholic acid(OCA) in combination with ursodeoxycholic acid (UDCA) in subjects withprimary biliary cirrhosis.

Key Inclusion Criteria

-   -   Male or female age 18-75 years and on a stable dose of UDCA for        at least 6 months prior to screening    -   Screening ALP level between 1.5× upper limit of normal (ULN) and        10×ULN    -   Proven or likely PBC, as demonstrated by the subject presenting        with at least 2 of the following 3 diagnostic factors:        -   History of increased ALP levels for at least 6 months prior            to Day 0        -   Positive antimitochondrial antibody (AMA) titer (>1:40 titer            on immunofluorescence or M2 positive by enzyme-linked            immunosorbent assay) or PBC-specific antinuclear antibodies            (antinuclear dot and nuclear rim positive)        -   Liver biopsy consistent with PBC

Key Exclusion Criteria

-   -   Use of colchicine, methotrexate, azathioprine, or systemic        corticosteroids    -   Screening conjugated (direct) bilirubin>2×ULN; ALT or AST>5×ULN;        serum creatinine>1.5 mg/dL (133 μmol/L)    -   History or presence of hepatic decompensation (e.g., variceal        bleeds, encephalopathy, or poorly controlled ascites)    -   History or presence of other concomitant liver diseases or human        immunodeficiency virus (HIV) or other viral hepatitis infection    -   Clinically significant medical condition, and gastrointestinal        conditions affecting drug ADME

The percent change (%) in serum ALP from Baseline to End of Study (EOS)was tested where [EOS=Day 85 or last observed ALP value on treatment]

Also observed were the absolute and percent changes in serum ALP levelsfrom Baseline to Day 15, Day 29, Day 57, Day 85/ET and Follow-Up (Day99). Patients were examined for the absolute and percent change in serumgamma-glutamyl transferase (GGT), alanine aminotransferase (ALT), andaspartate aminotransferase (AST) values from Baseline to Day 15, Day 29,Day 57, Day 85/ET and Follow-Up (Day 99). Patients were examined forabsolute and percent changes in serum albumin and conjugated (direct)bilirubin values from Baseline to Day 15, Day 29, Day 57, Day 85/ET andFollow-Up (Day 99). Patients' Enhanced liver fibrosis (ELF) score andchange in levels of its components, hyaluronic acid, aminoterminalpeptide of pro-collagen III, and tissue inhibitor of matrixmetalloproteinase-1 from Baseline to Day 85/ET were performed. Theabsolute and percent changes in levels of C-reactive protein,non-esterified fatty acid, tumor necrosis factor alpha, tumor necrosisfactor beta, tumor growth factor beta, bile acids, glutathione,immunoglobulin M, and osteopontin from Baseline to Day 85/ET were taken.

Bile acid analysis: Absolute and percent changes in the levels of totalbile acids and OCA plasma concentrations, and their conjugates, fromBaseline to Day 85/ET.

The absolute and percent change in fibroblast growth factor-19 (FGF-19)levels from Baseline to Day 85/ET were taken.

Overall, 165 subjects (100%) received at least 1 dose of investigationalproduct (ITT and Safety Populations) and 136 subjects comprised theCompleter Population. One hundred sixty-one subjects (98%) were includedfor the analysis of the mITT Population as measured by the percentchange in ALP from Baseline to EOS; the mITT Population for sensitivityanalysis of the primary endpoint included 163 subjects. It should benoted that the mITT population was defined for the primary analysis asall patients randomized who received at least one dose of studymedication and had at least one post-baseline ALP evaluation which wastaken at most seven days after their last dose of study medication. (SeeFIG. 10). The mITT Population for the sensitivity analysis included ALPassessments obtained up to 15 days after the last investigationalproduct use (unlike 7 days for primary endpoint). The number of subjectswas balanced across all groups in all analysis populations with theexception of the Completer Population due to the higher proportion ofdiscontinuations with OCA 50 mg.

TABLE 22 ALP (U/L) at Baseline to Day 85/ET: ITT Population (N = 165)and Completer Population (N = 136). Placebo OCA 10 mg OCA 25 mg OCA 50mg ITT Population (n = 38) (n = 38) (n = 48) (n = 41) Baseline Mean (SD)275.2 (102.7) 294.4 (149.4) 290.0 (123.6) 289.5 (106.2) Median 249.5234.8 255.8 262.5 Day 85/ET Mean (SD) 270.7 (118.7) 219.0 (113.5) 225.0(169.1) 227.9 (115.9) Median 234.5 177.5 187.5 197.0 Mean (SD) Change−4.6 (34.9) −75.4 (81.5) −65.0 (91.3) −62.9 (101.9) Median Change −6.3−47.5 −69.3 −56.5 Mean (SD) Percent −2.6 (12.4) −23.3 (17.1) −24.0(18.8) −20.0 (27.4) Change Median Percent −3.2 −21.0 −27.8 −22.7 ChangeP-value NA <0.0001 <0.0001 <0.0001 Completer (n = 37) (n = 32) (n = 42)(n = 25) Population Baseline Mean (SD) 276.4 (103.8) 298.6 (159.5) 274.9(80.2) 279.3 (110.5) Median 250.0 234.8 255.8 236.5 Day 85/ET Mean (SD)272.1 (120.0) 212.3 (120.2) 199.0 (59.8) 179.1 (63.6) Median 235.0 175.0187.5 158.5 Mean (SD) Change −4.3 (35.3) −86.3 (83.7) −76.0 (48.8)−101.8 (85.5) Median Change −6.0 −61.3 −71.3 −76.0 Mean (SD) Percent−2.5 (12.6) −26.7 (16.0) −26.6 (14.7) −32.5 (20.1) Change Median Percent−3.1 −23.5 −28.2 −33.9 Change

Example 9

This example describes a randomized, double-blind, placebo-controlled,parallel-group, 12-month trial evaluating OCA in patients with PBC as amonotherapy. The study was performed using a randomized, double-blind,placebo-controlled, parallel-group, in patients with PBC who either: (1)were on ursodeoxycholic acid (UDCA) for at least 12 months (and onstable dose for ≧3 months), or (2) were unable to tolerate UDCA, and didnot receive UDCA for 3 months prior to Day 0.

Where all eligibility criteria (see below) were met, participants werestratified into one of four groups, i.e., two factors each with twosub-categories (specified in parentheses):

-   -   pre-treatment ALP≧3.0×ULN and/or aspartate aminotransferase        (AST)≧2.0×ULN and/or TB ULN; (‘no’ for all three conditions,        ‘yes’ to at least one of the three conditions)    -   intolerance to UDCA; (‘no’ hence UDCA usage for at least 12        months, with a stable dose for at least 3 months, prior to study        start with the assumption of continued stable usage of UDCA        throughout the study; ‘yes’ hence no UDCA usage for at least 3        months prior to study start with the assumption of continued        non-usage of UDCA throughout the study).

Key Inclusion Criteria

-   -   Definite or probable PBC diagnosis as demonstrated by the        presence of 2 of the following 3 diagnostic factors:        -   History of elevated ALP levels for at least 6 months        -   Positive anti-mitochondrial antibody (AMA) titer or if AMA            negative or in low titer (<1:80) PBC specific antibodies            (anti-GP210 and/or anti-SP100 and/or antibodies against the            major M2 components [PDC-E2, 2-oxo-glutaric acid            dehydrogenase complex])        -   Liver biopsy consistent with PBC    -   At least 1 of the following qualifying biochemistry values:        -   ALP≧1.67×ULN or        -   Total bilirubin>ULN but<2×ULN    -   Age≧18 years    -   Taking UDCA for at least 12 months (stable dose for ≧3 months)        prior to Day 0, or unable to tolerate UDCA (no UDCA for ≧3        months) prior to Day 0.    -   Contraception: Female patients had to be postmenopausal,        surgically sterile, or if premenopausal, had to use ≧1 effective        (≦1% failure rate) method of contraception during the trial and        for 30 days after the EOT Visit.

Key exclusion criteria

-   -   Any hepatic decompensation        -   Portal hypertension, cirrhosis and complications of            cirrhosis/portal hypertension        -   History of liver transplantation, current placement on a            liver transplant list or current Model for End Stage Liver            Disease (MELD) score≧15        -   Cirrhosis with complications, including history or presence            of: spontaneous bacterial peritonitis, hepatocellular            carcinoma, bilirubin>2×ULN        -   Hepatorenal syndrome (type I or II) or Screening serum            creatinine>2 mg/dL (178 μmol/L)    -   Competing etiology for liver disease (e.g., hepatitis C, active        hepatitis B, nonalcoholic steatohepatitis (NASH), alcoholic        liver disease (ALD), autoimmune hepatitis, primary sclerosing        cholangitis, Gilbert's Syndrome)    -   Severe pruritus (Intense or widespread and interfering with        activities of daily living) or pruritus requiring treatment with        bile acid sequestrants, rifampicin within 2 months of day 0    -   On prohibited medications (such as fenofibrates, budesonide,        corticosteroids, valproate, isoniazid etc.); please see the list        of prohibited medications in protocol review.    -   Patients who had previously participated in a clinical trial of        OCA were not allowed to participate    -   Prolonged QT interval, pregnancy or lactation.    -   If female: known pregnancy, or had a positive urine pregnancy        test (confirmed by a positive serum pregnancy test), or        lactating    -   Known history of human immunodeficiency virus infection    -   Presence of any other disease or condition that was interfering        with the absorption, distribution, metabolism, or excretion of        drugs including bile salt metabolism in the intestine. Patients        with inflammatory bowel disease or who had undergone gastric        bypass procedures were excluded (gastric lap band was        acceptable).    -   Medical conditions that could cause non-hepatic increases in ALP        (e.g., Paget's disease)

One goal of the study was to demonstrate the efficacy of OCA, relativeto placebo, based on its effects on ALP and TB. Other objectivesincluded assessing safety, histological, bile acid, and biomarker (i.e.,not including ALP and TB) parameters.

ALP and TB composite response criteria were measured; a patient wasdesignated as a responder if all three of the following conditions weremet:

-   -   A value of ALP<1.67×ULN    -   ALP reduction from baseline≧15%    -   A value of TB<ULN

The absolute and percent change from Baseline in ALP, gamma-glutamyltransferase (GGT), alanine aminotransferase (ALT), AST, total bilirubin,conjugated (direct) bilirubin, albumin, prothrombin time andinternational normalized ratio (INR) at all-time points was measured.The percentage of patients with a decrease in ALP of ≧10%, ≧15%, ≧20%,and ≧40% from Baseline or ≦ULN at month 12 was measured. The percentageof patients achieving the following biochemical response criteria wasalso measured:

-   -   ALP≦3×ULN and AST≦2×ULN and bilirubin≦ULN ((Corpechot 2008);        Paris I)    -   ALP≦1.5×ULN and AST≦1.5×ULN and bilirubin ULN ((Corpechot≦2011),        Paris II)    -   ALP≦1.67×ULN and bilirubin≦ULN ((Momah 2012), Mayo II)    -   ALP≦1.76×ULN ((Kumagi 2010b), Toronto II)    -   Normal bilirubin (values ULN) and/or normal albumin (values        lower limit of normal [LLN]; (Kuiper 2009) [Rotterdam criteria])

The absolute change from Baseline for enhanced liver fibrosis (ELF) andhepatic stiffness (at select sites) as assessments of end stage liverfailure. The absolute and percent change from Baseline on: C-reactiveprotein (CRP), tumor necrosis factor-alpha (TNF-α), tumor necrosisfactor-beta (TGF-β), fibroblast growth factor-19 (FGF-19) levels,interleukin-6 (IL-6), and CK-18 was measured. The absolute and percentchange from Baseline on PBC-40 domains was measured.

Absolute and percent change from Baseline on PBC autoantibodies (IgA,IgG, IgM) and interleukins (IL-12 [p40], IL-23) were measured.

Measuring the plasma OCA concentrations including OCA (unconjugated),conjugates (glyco-OCA and tauro-OCA), and total OCA (the sum of OCAunconjugated, glyco-OCA, and tauro-OCA).

Measuring the absolute change from Baseline for total bile acids,endogenous bile acids, and individual total and unconjugated bile acids(UDCA, deoxycholic acid, cholic acid and lithocholic acid),glyco-conjugate, and tauro-conjugate; proportion of each of theindividual bile acids to total bile acids

Bile acid sequestrant (BAS) concomitant exposure. The primary analysisset used for all efficacy analyses, along with the summarization ofdisposition along with demographics and baseline characteristics, wasthe Intent-to-Treat′ (ITT) analysis set. This analysis set included allrandomized patients who received at least one dose of blinded studydrug. When utilizing this analysis set, patients were analyzed accordingto the treatment group that they were randomized to regardless of theactual treatment received. It should be noted that all but onerandomized patient received at least one dose of blinded study drug.

For sensitivity analysis purposes, all efficacy analyses were repeatedutilizing a ‘Completer’ analysis set. This analysis set was comprised ofall ITT patients who participated through the end of the double-blindperiod (i.e., through the Month 12 visit). When utilizing this analysisset, patients were analyzed according to the treatment group that theywere randomized to, regardless of the actual treatment received.

For additional sensitivity analysis purposes, all efficacy analyses wereagain repeated utilizing an ‘Efficacy Evaluable’ (EE) analysis set. Thisanalysis set was comprised of all ‘Completer’ patients who did not haveany major protocol deviations that would potentially affect the efficacyof the study drug. This analysis set definition was finalized in ablinded manner prior to database lock.

For population pharmacokinetic (PK) analysis purposes, the PK analysisset was utilized, which consisted of all patients who had at least 1confirmed fasted analyzable sample at and who did not have any majorprotocol deviations that could potentially affect exposure levels.

To control the overall study-wise type I error rate, a step-down/closedsequential testing procedure was pre-specified to adjust for themultiple comparisons of the two OCA dose groups individually to placeboon the primary study endpoint alone. Starting with the 10 mg OCAcomparison to placebo on the primary endpoint, the step-down could onlybe carried to the OCA Titration comparison to placebo (on the primaryendpoint), if and only if the 10 mg OCA comparison to placebo was foundto be statistically significant (i.e., p-value less than 0.05). If the10 mg OCA comparison to placebo was not statistically significant (i.e.,p-value greater than or equal to 0.05), then the hypothesis test for theOCA Titration comparison to placebo on the primary endpoint would bedeemed as exploratory.

This pre-specified multiplicity adjustment procedure was narrow in scopein that it only pertained to the individual OCA dose comparisons withplacebo on the primary endpoint alone. Hence even if both OCA dosecomparisons were found to be statistically significant, then any otherhypothesis test would still be deemed as exploratory in nature.

A Cochran-Mantel-Haenszel (CMH) test which adjusted for bothrandomization stratification variables as described above, was used forpre-specified analysis. In tandem with the CMH test, a Breslow-Day testwas also conducted, to test for the homogeneity of the treatment effectacross the different randomization strata.

The PK population was used to summarize OCA and bile acidconcentrations. The change from Baseline concentrations within eachtreatment group was compared using a paired t-test. Descriptivestatistics of OCA plasma concentrations and the extent of BASconcomitant exposure were provided by treatment group. Initialevaluation of the effects of BAS on OCA, total bile acid concentrations,and ALP was performed using a correlation analysis.

It can be observed from Table 23 that both OCA treatment groups showed asuperior difference in the proportion/percentage of patients achievingresponse at Month 12 when individually compared to placebo using the CMHtest. The corresponding Breslow-Day test result shows that the treatmenteffects were homogeneous across the different randomization strata. Thisanalysis was repeated utilizing the Completer and EE analysis sets andthe conclusions were consistent. The ultra-worse-case imputationstrategy, implemented by the FDA statistical reviewer as describedabove, did not impact the study conclusions. In regards to ALP or TBvalues at Month 12, there were no patients who were designated asoutliers (i.e., by having studentized residual values greater thanthree), and there was no impact on study conclusions between corrected30 laboratory values (as presented) and original (i.e., uncorrected)laboratory values. All of the previously presented analyses werere-conducted utilizing a baseline value that was the median of allpre-first dose measurements, and, separately, a traditional baselinedefinition (both approaches as described above); there was no impact onstudy conclusions with either approach. Considering the pre-specifiedstep-down/closed sequential testing procedure as previously described,formal hypothesis testing is stopped at this point. Any subsequentinferential statistic reported below should be considered exploratory

TABLE 23 Proportion of Patients who Achieved Response 10 mg OCA OCATitration Placebo Statistics (N = 73) (N = 70) (N = 73) Response atMonth 6 - 37 (50.7%) 24 (34.3%) 5 (6.9%) n (|%) [1] Corresponding 95%39.2%, 62.2% 23.2%, 45.4% 1.1%, 12.6% Wald CI Response at Month 12 - 34(46.6%) 32 (45.7%) 7 (9.6%) n (%) [1] Corresponding 95% 36.5%, 59.4%34.0%, 57.4% 2.8%, 16.3% Wald CI CMH Test p-value [2] <0.0001 <0.0001Corresponding 0.9072 0.5045 Breslow-Day Test p-value

It can be observed from Table 24 that both OCA treatment arms reducedALP relative to placebo. It should be noted that the continuousdescriptive statistics pertaining to the baseline absolute change frombaseline 12 and percentage change from baseline utilized only theavailable data at those time points (i.e., no missing data wereimputed). The categorical descriptive statistics (i.e., frequencies andcorresponding proportions) utilized the worse-case (i.e., non-response)imputation strategy.

Patients from the OCA Titration and OCA 10 mg groups, respectively,achieved an ALP reduction from Baseline≧40% compared with 1 (1%) placebopatient. The numbers of patients normalizing ALP values i.e., 118 U/L infemales and 124 U/L males are as follows: 1 (1%) patient from OCAtitration group, 5 (7%) patients from the OCA 10 mg group, and zeroplacebo-treated patients.

It can be seen that ALP concentration levels are reduced in both OCAtreatment groups, and during the first three months; these reducedlevels remain stable during the long-term safety and efficacy (LTSE)period, signifying durability of response.

TABLE 24 Total Bilirubin (TB) Summary. 10 mg OCA OCA Titration PlaceboTime Point/Statistics (N = 73) (N = 70) (N = 73) Baseline ALPConcentration (U/L) N 73 70 73 Mean (SD) 316.3 (103.88) 325.9 (116.24)327.5 (115.01) Median 271.3 281.3 311.9 Min, Max 207, 620 187, 811 144,746 Month 12 ALP Concentration (U/L) N 63 64 70 Mean (SD) 191.2 (61.38)219.5 (99.76) 321.3 (142.88) Median 181.7 196.6 270.5 Min, Max 95, 444116, 690 149, 733 Absolute Change from Baseline to Month 12 (U/L) N 6364 70 Mean (SD) −11|7.1 (72.84) −103.5 (87.03) −7.7 (87.96) Median −99.0−85.5 −15.8 Min, Max −346, 0.3 −402, 127 −208, 308 Percentage Changefrom Baseline to Month 12 (%) N 63 64 70 Mean (SD) −36.4 (14.88) −30.5(18.97) −2.5 (23.82) Median −38.3 −31.5 −4.7 Min, Max −72, 0.1 −74, 23−45, 80 Decrease in ALP ≧ 10% at 61 (83.6%) 55 (78.6%) 29 (39.7%) Month12 - n (%) Decrease in ALP ≧ 15% at 57 (78.1%) 54 (77.1%) 21 (28.8%)Month 12 - n (%) Decrease in ALP ≧ 20% at 54 (74.0%) 49 (70.0%) 17(23.3%) Month 12 - n (%) Decrease in ALP ≧ 40% at 25 (34.3%) 21 (30.0%)1 (1.4%) Month 12 - n (%) Baseline ALP Concentration (×ULN) N 73 70 73Mean (SD) 2.658 (0.878) 2.747 (0.9851) 2.760 (0.9732) Median 2.293 2.3782.607 Min, Max 1.68, 5.23 1.58, 6.86 1.22, 6.31 Month 12 ALPConcentration (×ULN) N 63 64 70 Mean (SD) 1.606 (0.5161) 1.851 (0.8449)2.705 (1.1987) Median 1.527 1.661 2.286 Min, Max 0.80, 3.75 0.98, 5.841.26, 6.19 ALP < 1.0 × ULN at 5 (6.9%) 1 (1.4%) 0 Month 12 - n (%) ALP <1.67 × ULN at 48 (54.8%) 33 (47.1%) 12 (16.4%) Month 12 - n (%)

After completing the treatment period, 193 out of the 216 ITT patients(64 on 10 mg OCA, 63 on OCA Titration, and 66 Placebo patients)continued on open-label OCA treatment during the LTSE period (note: thatall placebo patients were switched to OCA 5 mg and then all patientswere switched to OCA 10 mg). FIG. 11 presents ALP concentrations overtime, organized by originally randomized treatment group.

It can be observed from Table above that reductions from baseline in TBwere greater in both OCA treatment groups than in the placebo group. Itshould be noted that the continuous descriptive statistics pertaining tothe baseline, absolute change from baseline and percentage change frombaseline values utilized only the available data at those time points(i.e., no missing data was imputed). The categorical descriptivestatistics (i.e., frequencies and corresponding proportions) utilizedthe worse-case imputation strategy. FIG. 12 illustrates TBconcentrations over time, organized by originally randomized treatmentgroup for the 193 ITT patients continuing on open-label OCA treatmentduring the LTSE period.

Dose Titration: A total of 69 of 70 ITT patients from the OCA titrationgroup completed month 6. Of these, 36 (52%) remained at 5 mg for theduration of the treatment period and 33 (48%) who did not meet theprimary composite endpoint at Month 6, but, because they tolerated theinvestigational product, were titrated to 10 mg. Thirteen (39%) of thepatients who up-titrated met the composite endpoint suggesting that abenefit can be gained with titration of OCA from 5 mg to 10 mg in thosepatients who did not respond to the 5 mg dose.

Because for some patients, a response can be achieved with OCA 5 mg,initiating treatment on OCA 5 mg and titrating subsequently to 10 mg ifneeded and if tolerated appears to be a reasonable dosing strategy. Forpatients who do not achieve an optimal response within 6 months oftreatment with OCA 5 mg, additional benefit may be gained by titratingto OCA 10 mg.

Effect of Bile Acid Sequestrants (BAS) Exposure on Efficacy. Forpatients receiving BAS, OCA 5 mg and 10 mg trough concentrations wereslightly lower compared to those patients who did not receive BAS. Thedecreased trough concentrations resulted in a modest attenuation inefficacy in patients receiving OCA 5 mg (despite instruction to dose BSat least 4 hours apart from OCA), but did not appear to affect efficacyin patients receiving OCA 10 mg.

ALP and total bilirubin, were evaluated in relation to age at baseline,age at time of diagnosis, and years since diagnosis. The effect of OCAwas consistent independent of age at diagnosis, duration of PBC, oryears since diagnosis. In general, the subgroups were consistent withthe observed effect in the overall ITT population. Greater improvementswere observed in OCA-treated subjects, compared with placebo subjects.

It can be observed from Table 25 that both OCA treatment groups showed adifference in the proportion/percentage of patients achieving responsewhen individually compared to placebo. This analysis was repeatedutilizing the Completer and EE analysis sets and the conclusions wereconsistent. The ultra-worse-case imputation strategy, implemented by theFDA statistical reviewer as described above, did not impact the results.All of the previously presented analyses were re-conducted utilizing abaseline value that was the median of all pre-first dose measurements,and, separately, a traditional baseline definition (both approaches asdescribed above); there was no impact on the results with eitherapproach.

TABLE 25 Proportion of Patients who Achieved Response 10 mg OCA OCATitration Placebo Statistics (N = 60) (N = 60) (N = 61) Response atMonth 6 - n (%) [1] 25 (41.7%) 21 (35.0%) 1 (1.6%) Corresponding 95%Wald CI 29.2%, 54.1% 22.9%, 47.1% 0.0%, 4.8% Baseline ALP ≧ 2.0 × ULN -n (%) 42 (70.0%) 47 (78.3%) 46 (75.4%) ALP < 2.0 × ULN at Month 6 - n(%) [2] 30 (71.4%) 24 (51.1%) 8 (17.4%) Decrease in ALP ≧ 40% at Month6 - n (%) [2] 10 (23.8%) 13 (27.7%) 0 ALP < 2.0 × ULN and Decrease ≧ 40%at Month 6 - n (%) [2] 9 (21.4%) 11 (23.4%) 0 Baseline ALP ≧ 1.67 × ULNbut < 2.0 × ULN - n (%) 18 (30.0%) 13 (21.7%) 15 (24.6%) ALP < 1.67 ×ULN at Month 6 - n (%) [3] 17 (94.4%) 10 (76.9%) 3 (20.0%) Decrease inALP ≧ 15% at Month 6 - n (%) [3] 16 (88.9%) 11 (84.6%) 1 (6.7%) ALP <1.67 × ULN and Decrease ≧ 15% at Month 6 - n (%) [3] 16 (88.9%) 10(76.9%) 1 (6.7%) Response at Month 12 - n (%) [1] 26 (43.3%) 23 (38.3%)3 (4.9%) Corresponding 95% Wald CI 30.8%, 55.9% 26.0%, 50.6% 0.0%, 10.3%Baseline ALP ≧ 2.0 × ULN - n (%) 42 (70.0%) 47 (78.3%) 46 (75.4%) ALP <2.0 × ULN at Month 12 - n (%) [2] 29 (69.1%) 28 (59.6%) 9 (19.6%)Decrease in ALP ≧ 40% at Month 12 - n (%) [2] 13 (31.0%) 16 (34.0%) 1(2.2%) ALP < 2.0 × ULN and Decrease ≧ 40% at Month 12 - n (%) [2] 12(28.6%) 13 (27.7%) 1 (2.2%) Baseline ALP ≧ 1.67 × ULN but < 2.0 × ULN -n (%) 18 (30.0%) 13 (21.7%) 15 (24.6%) ALP < 1.67 × ULN at Month 12 - n(%) [3] 16 (88.9%) 11 (84.6%) 6 (40.0%) Decrease in ALP ≧ 15% at Month12 - n (%) [3] 14 (77.8%) 10 (76.9%) 2 (13.3%) ALP < 1.67 × ULN andDecrease ≧ 15% at Month 12 - n (%) [3] 14 (77.8%) 10 (76.9%) 2 (13.3%)

Treatment with OCA (10 mg) in a cohort of subjects with early stage PBCwho were enrolled with incomplete biochemical response to UDCA resultedin statistically significant improvement from baseline in alkalinephosphatase for the pre-specified endpoint of reduction of ALP to<1.67×ULN and 15%, relative to placebo. The percentage of patientsachieving response was statistically significantly different thanplacebo [34 of 73 (46.6%) in the OCA 10 mg arm, 32 of 70 (45.7%) in thetitration arm and 7 of 73 (9.6%) in the placebo arm]. The effect of OCAon achieving a reduction in ALP was independent of age at diagnosis,duration of PBC, and baseline ALP.

Secondary analysis showed that patients from the OCA Titration and OCA10 mg groups achieved an ALP reduction from Baseline≧40% compared with 1(1%) placebo patient. The numbers of patients normalizing ALP valuesi.e., 118 U/L in females and 124 U/L males are as follows: 1 (1%)patient from OCA titration group, 5 (7%) patients from the OCA 10 mggroup, and zero placebo-treated patients.

Example 10

This example describes clinical pharmacology and dosing of obeticholicacid (OCA—including obeticholic acid compositions described herein). Thestarting dosage of OCA is 5 mg orally once daily in adult patients whohave failed to achieve an adequate reduction in alkaline phosphatase ona stable dose of UDCA for an adequate duration or who were intolerant toUDCA. OCA can be supplied as an oral tablet containing obeticholic acidin a formulation as described herein.

If an adequate reduction in alkaline phosphatase has not been achievedafter 3 months of OCA 5 mg once daily, and the patient is tolerating thedrug, the dose of OCA can be increased to 10 mg once daily.

For patients experiencing intolerability due to pruritus, one of thefollowing modifications was considered:

-   -   Reduce the dosage to:        -   5 mg every other day, for patients intolerant to 5 mg once            daily or        -   5 mg once daily, for patients intolerant to 10 mg once daily    -   Alternative dosing schedules, such as dosing every other day,        every third day or every seventh day.    -   Interruption of dosing for up to 2 weeks followed by restarting        at a reduced dose or on an alternative dosing schedule.    -   hepatic decompensation.    -   Addition of an antihistamine or a bile acid sequestrants.

OCA may be taken with or without food. Food does not have a clinicallyrelevant effect on the PK of 10 mg OCA.

Bile acid binding resins may be taken at least 4 hours before or 4 hoursafter (or at as great an interval as possible) OCA. Bile acid bindingresins such as cholestyramine, colestipol, or colesevelam affect bileacid absorption and may reduce the absorption, systemic exposure, andefficacy of OCA.

No dose adjustment is believed to beneeded when OCA is used in patientswith serum creatinine clearance>50 mL/min/1.73 m². No data are availableas to how severe impairment would impact the systemic exposure to OCAand its conjugates.

Dose adjustment may be needed in patients with hepatic impairment. Doseadjustment may not be needed in patients with mild hepatic impairment(Child-Pugh Class A). In some examples, the starting dosage is 5 mg onceweekly for patients with moderate or severe hepatic impairment(Child-Pugh Class B or C). If an adequate reduction in alkalinephosphatase has not been achieved after 3 months of OCA 5 mg onceweekly, and the patient is tolerating the drug, the OCA dose should beincreased to 5 mg twice weekly and then to 5 mg every day depending onresponse and tolerability.

Obeticholic acid is absorbed with peak plasma concentrations (Cmax)occurring at a median time (tmax) of approximately 2 hours.Co-administration with food does not alter the extent of absorption ofobeticholic acid. Following multiple-dose administration of 5, 10, and25 mg once daily for 14 days, systemic exposures of obeticholic acidincrease dose proportionally. Exposures to glyco-obeticholic acid andtauro-obeticholic acid, and total obeticholic acid increase more thanproportionally with dose.

Following multiple oral doses of OCA 10 mg once daily, peak plasmaconcentrations (Cmax) of OCA occurring at a median time (Tmax) ofapproximately 1.5 hours. Median T_(max) for glyco-OCA and tauro-OCA is10 hours.

Distribution. Human plasma protein binding of obeticholic acid and itsconjugates is greater than 99%. The volume of distribution of OCA is 613L. The volume of distributions of glycol- and tauro-obeticholic acid hasnot been determined.

Elimination and Metabolism. Obeticholic acid is conjugated with glycineor taurine in the liver and secreted into bile. These glycine andtaurine conjugates of obeticholic acid are absorbed in the smallintestine leading to enterohepatic recirculation. The conjugates can bedeconjugated in the ileum and colon by intestinal microbiota, leading tothe conversion to obeticholic acid that can be reabsorbed or excreted infeces, the principal route of elimination.

After daily administration of obeticholic acid, there is accumulation ofthe glycine and taurine conjugates of obeticholic acid which have invitro pharmacological activities similar to the parent drug, obeticholicacid. The metabolite-to-parent ratios of the glycine and taurineconjugates of obeticholic acid were 13.8 and 12.3, respectively, afterdaily administration. An additional third obeticholic acid metabolite,3-glucuronide is formed but is considered to have minimal pharmacologicactivity.

Excretion. After administration of radiolabeled obeticholic acid,greater than 85% is excreted in feces. Urinary excretion is less than3%.

The proposed human metabolic pathways are shown in FIG. 13.

Following an oral administration of 25 mg [¹⁴C]-OCA, about 87% of thedose is excreted in feces through biliary secretion. Less than 3% of thedose is excreted in the urine with no detection of OCA.

The effective half-life of OCA is about 24 hours.

Gender, age, and race had no impact on the pharmacokinetics of OCA basedon the population-PK analysis. Population PK analysis dataset consistedof 301 female and 505 male subjects, age ranging from 18 to 71 years andhad 10 Asian, 233 Black, 554 White and 9 Other subjects.

In vitro studies: Obeticholic acid is not an inhibitor of CYP2C8 and didnot cause a significant change in the expression of CYP2B6, CYP2C8,CYP2D6, MRP2, MRP3, MRP4, MATE1, and OATP2B1. Obeticholic acid showedeither no or weak effects on these metabolizing enzymes andtransporters.

Concomitant administration of 20 mg omeprazole once daily withobeticholic acid 10 mg once daily resulted in a less than 1.2-foldincrease in obeticholic acid exposure.

Treatment with obeticholic acid 10 mg or obeticholic acid titration (5mg to 10 mg) resulted in clinically meaningful and statisticallysignificant increases (p<0.0001) relative to placebo, in the number ofpatients achieving the primary composite endpoint at all study timepoints (see Table 26). Responses occurred as early as 2 weeks and weredose dependent (obeticholic acid 5 mg compared with obeticholic acid 10mg at 6 months, p=0.04).

TABLE 26 Percentage of Patients Achieving Response.^(A) Obeticholic acid± UDCA ^(B) Obeticholic acid Obeticholic acid Titration ^(C) 10 mgPlacebo ± UDCA ^(B) (N = 70) (N = 73) (N = 73) Month 6 Dose 5 mg 10 mgResponders, 24 (34) 37 (51) 5 (7)  n (%) p-value ^(D) <0.0001 <0.0001 NAMonth 12 Dose 5 mg or 10 mg 10 mg Responders, 32 (46) 34 (47) 7 (10) n(%) p-value ^(D) <0.0001 <0.0001 NA NA = not applicable ^(A)Percentageof Subjects Achieving an ALP less than 1.67 × ULN and Total Bilirubinless than or equal to the ULN and an ALP decrease of 15% or greater.Missing values were considered a non-response. ^(B) The majority ofpatients received treatment in combination with UDCA and a small numberof patients unable to tolerate UDCA received obeticholic acid asmonotherapy. ^(C) Subjects randomized to obeticholic acid titrationreceived obeticholic acid 5 mg for the initial 6-month period. At Month6, patients who did not achieve the composite endpoint and did not haveevidence of tolerability issues were titrated from 5 mg to 10 mg for thefinal 6 months of the double-blind phase. ^(D) p-values for comparingobeticholic acid versus placebo are obtained using CMH GeneralAssociation test stratified by double-blind Baseline UDCA usage (yes/no)and double-blind Baseline total bilirubin (less than or equal to theULN/greater than the ULN).

In one example, 77% of patients on both titration and 10 mg obeticholicacid achieved a reduction of at least 15% in ALP at 12 months comparedto 29% of patients on placebo (see FIG. 14A, FIG. 14B, FIG. 14C). Inaddition, 36% of patients treated with placebo experienced an increasein ALP associated with worsening of disease compared to 5% of patientson titration obeticholic acid and 2% on 10 mg obeticholic acid.

Treatment with obeticholic acid also resulted in clinically meaningfuland statistically significant improvements versus placebo (p<0.0001) inALP levels as early as 2 weeks and at all timepoints thereafter (seeFIG. 15A, FIG. 15B). During the double-blind, 12 month period, bilirubinlevels increased in the placebo patients and remained stable in patientstaking obeticholic acid.

Patients randomized to the obeticholic acid titration group receivedobeticholic acid 5 mg for the initial 6-month period. At Month 6,patients who did not yet meet the criteria for the composite endpointand did not have evidence of tolerability issues were titrated fromobeticholic acid 5 mg to obeticholic acid 10 mg for the final 6 monthsof the double-blind phase. SE=standard error.

The above dosing regimen including a 5 mg QD starting dose, followed byup-titration to 10 mg QD at 3 months was based on response andtolerability for the overall population. Based on the dose dependentincrease in incidences of pruritus and better tolerability profile withtime with a lower starting dose, 5 mg QD (once daily) is an effectivestarting dose for the general population.

The increase in dose from 5 mg to 10 mg QD resulted in additionalresponders from month 6 to month 12. There were also 19% patients (outof patients on 5 mg QD dosing) who were responders (as per the primarycomposite endpoint criteria), but became non-responders, possibly due todisease progression, with continued dosing of 5 mg QD. These patientsalso benefit from up-titration to 10 mg QD.

In the dedicated hepatic impairment study with a single dose of 10 mg,the systemic exposure (AUC0-9 days) to total OCA was 1.1-, 4.2-, and17.3-fold in subjects with mild, moderate and severe hepatic impairment,respectively, when compared to normal healthy volunteers. The mean totalOCA concentration-time profiles in this study are shown in FIG. 16 andthe mean PK parameters (Cmax and AUCt) for total OCA in plasma fornormal healthy volunteers and subjects with various categories ofhepatic impairment are quantified in Table 27.

TABLE 27 Mean (SD) PK parameters of plasma total OCA. Normal HepaticFunction Mild Moderate Severe Parameters (N = 8) (N = 8) (N = 8) (N = 8)Cmax (ng/mL) 68.3 (27.6)  107 (65.1) 348 (377) 674 (281) AUC0-t 2480(1810) 2770 (2060) 15700 (19100) 41000 (21900) (hr*ng/mL)

There was no apparent association of change of unbound free fractionpercentage (% Fu) of OCA and tauro-OCA with the increased degree ofhepatic impairment. Mean % Fu of glyco-OCA increased in patients withsevere hepatic impairment.

Example 11

Obeticholic acid (OCA) is a farnesoid X receptor (FXR) agonist and asshown, inter alia, useful for the treatment of primary biliarycholangitis/cirrhosis (PBC), nonalcoholic steatohepatitis (NASH), andother liver diseases. OCA is the 6α-ethyl derivative of chenodeoxycholicacid (CDCA). Patients with cirrhosis have systemic bile acid exposurehigher than those in healthy subjects (×18) while hepatic bile acidexposure is only ˜2× higher. Thus systemic OCA exposure may not bereflective of OCA concentrations in the liver or intestine, the primarysites of action.

Plasma levels of OCA and its conjugates were measured in healthysubjects and cirrhotic patients with varying degrees of hepaticimpairment. A physiologic pharmacokinetic model for OCA was developed toquantitatively describe the absorption, distribution, metabolism, andexcretion of OCA in patients with and without hepatic impairment. Themodel was based on a published multi-compartment PK model for CDCA, andconsisted of systemic, hepatobiliary, and intestinal systems. The modelwas used to simulate the pathophysiological abnormalities caused bycirrhosis including decreased hepatic uptake, portal-systemic shunting,decreased liver volume, and differences in amino acid conjugation.

There was good agreement between predicted and observed increases insystemic OCA exposure after a single 10 mg dose in subjects with mild(×1.4), moderate (×8), and severe (×13) hepatic impairment relative tohealthy subjects. The predicted increases in liver exposure for subjectswith mild, moderate, and severe hepatic impairment were increased only1.1-, 1.5-, and 1.7-fold, relative to healthy participants. Hepaticexposure of OCA, the primary site of pharmacological activity, isincreased marginally (˜2-fold) in patients with cirrhosis.

Bile acids are the natural endogenous ligand for the farnesoid Xreceptor (FXR) which is a nuclear receptor with high expression levelsin the liver and intestine. Nuclear receptors constitute a family ofligand-activated transcription factors which can either activate orrepress target genes, including those involved in bile acid homeostasis.FXR activation appears to lead to decreased bile acid synthesis viaCYP7A1 suppression, decreased conjugated bile acid uptake, and increasedexcretion from the hepatocytes via induction of transporters.Obeticholic acid (OCA, 6-ethyl chenodeoxycholic acid) is a FXR agonist.OCA is a modification of chenodeoxycholic acid (CDCA), the most potentendogenous agonist of FXR and differs from CDCA by the addition of anethyl group at the 6 carbon position. The addition of this ethyl groupto CDCA confers approximately 100-fold greater potency compared to CDCA.

PBC is a rare chronic autoimmune disease characterized by T-cellmediated destruction of the intrahepatic bile ducts, decreased bilesecretion, bile acid retention in the liver, inflammation, fibrosis,cirrhosis, and liver failure, followed by either liver transplantationor death. NASH is a chronic liver disease often associated with type 2diabetes or metabolic syndrome which is defined by presence of hepaticsteatosis, inflammation, and cytological ballooning with eventualvarying degrees of fibrosis and possible cirrhosis leading to livertransplantation, hepatocellular carcinoma or death. In general, chronicinjury to the liver can lead to the formation of regenerative nodulesand fibrous bands in the liver that form after an extended process offibrosis. Cirrhosis causes the interface between the sinusoids and thehepatocytes to fill with fibrotic tissue leading to increased resistanceto hepatic blood flow causing portal hypertension and its associatedcomplications. Previous reports have shown that patients with cirrhosishave systemic bile acid exposure markedly higher than those in healthysubjects (18-fold higher) while hepatic bile acid exposure was only˜2-fold higher.

There are 4 primary mechanisms of hepatic impairment that are related tothe pharmacokinetics of endogenous bile acids and OCA: reduced hepaticuptake (caused in part by capillarization of the sinusoids), portalsystemic shunting (both hepatic and extrahepatic), decreased functionalliver volume, and increased taurine conjugation. Mild liver disease maybe associated with little or no change in the hepatic uptake of bileacids but severe cirrhosis and/or jaundice causes large decreases in theextraction ratio that affects all bile acids similarly. Healthy controlsubjects have hepatic uptakes of bile acids of at least 70%. Incontrast, values in cirrhotic patients were reduced over a wide range ofvalues with some less than 10%.

Portosystemic shunting appears to occur secondary to the development ofportal hypertension. With ongoing liver injury, resultant fibrogenesisand the occurrence of nodular regeneration, intrahepatic resistanceincreases. When coupled with increased splanchnic blood flow into theliver that occurs as a result of splanchnic vasodilation in cirrhotics,portal pressures can become elevated and blood is shunted throughcollateral vessels, away from the liver. Portosystemic shunting canoccur via either diversion of blood through newly developed veins or viaanastomoses (“shunts”) formed between existing portal and hepatic veinsand is associated with higher systemic bile acid concentrations.Relative to normal controls, the portal blood flow was 91%, 64%, and55%, for Child-Pugh scores -A, -B, and -C, respectively. In response tothe decreased portal blood flow to the liver, the hepatic arterial bloodflow increased by 41%, 63%, and 92% for Child Pugh-A, -B, and -C,relative to normal controls. This increase in arterial blood flow inresponse to decreased portal blood flow is termed hepatic arterialbuffer response and allows for relatively constant blood flow to theliver regardless of portosystemic shunting. The SimCYP library forcirrhotic subjects uses a decrease of 89%, 71%, and 61% in functionalliver size relative to control subjects in subjects with Child-PughScore-A, -B, and -C, respectively, based on meta-analyses (SimCYPsimulator Version 11; Simcyp Limited, Sheffield, UK).

Bile acids are metabolized in the liver, primarily by conjugation(N-acylamidation) to the amino acids glycine or taurine. In healthyhumans, a normal adult ratio of glycine to taurine bile acid conjugation(“G/T ratio”) is 3:1 with a range of 1:1 to 5:1. Dietary intake oftaurine increases the proportion of bile acids conjugated with taurine.In contrast, oral ingestion of glycine does not change the G/T ratio.The G/T ratio in healthy and disease states appears to be governed bythe liver as opposed to intestinal control via preferentialdeconjugation of glycine conjugated bile acids by bacteria orpreferential conjugate uptake into the enterocytes. It has been reportedin the literature that the G/T ratio is decreased in patients withcirrhosis.

A physiologic pharmacokinetic model exists describing the metabolism andenterohepatic circulation of CDCA. The CDCA model included 9 spacesbased on anatomical and physiological considerations (systemiccirculation, portal circulation, sinusoidal circulation, liver, bileduct, gallbladder, duodenum-jejunum, ileum, and colon) with each spacepossessing a compartment of either CDCA, glycine-conjugated CDCA(glyco-CDCA), or taurine-conjugated CDCA (tauro-CDCA). The modelincluded transfer coefficients describing fluid flow, biotransformationof chemical entities, and transport across membranes.

Without being bound by any particular theory, due to the similarstructure of CDCA, OCA was considered to have comparable pharmacokineticproperties when compared to CDCA. This examples describes development ofa physiologic PK model to quantitatively describe the absorption,distribution, metabolism, and excretion of OCA. In addition, the modelwas used to define the effects of hepatic impairment to predict thesystemic and liver exposure to OCA in subjects with various degrees ofliver impairment relative to healthy subjects with normal liverfunction. The model was developed based on 3 studies in healthyvolunteers and 2 studies in patients with varying degrees of hepaticimpairment (N=399).

All participants in each of the studies were over 18 years of age andprovided informed consent for willing participation. The studies wereconducted in accordance with the Declaration of Helsinki (Seoul 2008Revision) and adhered to guidelines for Good Clinical Practices and wereapproved by all relevant ethics committees.

Data from was used to develop the model in healthy subjects (n=160) andthen adjust for hepatic impairment (n=32) using the data from the aboveExamples. After development, the model was validated with data sourcedfrom healthy subjects and cirrhotic patients.

The data used in model development included subject identifiers, time ofdosing and sample collection, plasma drug concentrations (OCA,glyco-OCA, and tauro-OCA), dose amount, disease status (e.g., Child-Pughscore), and meal consumption information. Study participants receivedstandardized meals at specified times during inpatient observation.Gallbladder contraction was assumed to last 90 minutes after the startof a meal. Drug concentrations below the limit of quantification (BLQ)were imputed to half of the lower limit of quantification (LLOQ).Observed and BLQ concentrations of OCA, glyco-OCA, and tauro-OCAassociated with samples drawn prior to the first dose were excluded fromthe analyses. As the glyco- and tauro-conjugates are nearly equipotentrelative to OCA on FXR, total OCA concentrations were calculated as thesum of OCA, glyco-OCA, and tauro-OCA.

Concentrations of OCA (420.6 g/mol), glyco-OCA (477.7 g/mol), andtauro-OCA (527.8 g/mol) were measured from human plasma samples usinghigh performance liquid chromatography tandem mass spectrometry(LC-MS/MS) (Shimadzu 10AVP HPLC System, Kyoto, Japan; AB MDX SciexAPI-4000 LC-MS/MS System, Framingham, Mass.). The LLOQ for OCA,glyco-OCA, and tauro-OCA was 0.594 nM, 0.523 nM, and 0.474 nM,respectively.

The PK model developed for CDCA used 27 compartments consisting of 9spaces with anatomical and physiological considerations, each requiringthree compartments to accommodate CDCA, glyco-CDCA, and tauro-CDCA.Division of each space into 3 compartments was necessary because whileflow rates (e.g., blood flow) were independent of chemical structure,biotransformation rates (e.g., conjugation and deconjugation) andtransport rates (e.g., hepatic uptake) differed based on chemicalstructure. Values for the physiologic compartment volumes and transferrates used in the model were obtained from the literature. To constructthe PK model for OCA, the physiologic PK model for CDCA was structurallymodified to accurately reflect the interaction of human physiology andOCA.

A number of structural modifications were made to the base CDCA model inorder to adapt it for use with OCA. For simplification, a single spacewas used to represent the gut (small and large intestines). Since OCA isan exogenous molecule, it was assumed that there was no endogenoussynthesis and an absorption compartment with a first-order transfercoefficient (K_(a)) was included to represent the administration andabsorption kinetics of an oral OCA dose. Based on steric hindrance bythe 6-ethyl group of OCA, no bacterial 7-alpha dehydroxylationbiotransformation activity (i.e., CDCA to lithocholic acid) was includedin the model. Compartment volumes in the model were fixed tophysiological values from the base CDCA model. The OCA model used thephysiological flow values for blood, bile and gastrointestinal transitfrom the original physiologic PK model for CDCA, with the exception offlows from bile duct to gallbladder and from bile duct to gut. Thephysiological values from the base model led to poor predictions and maynot be applicable due to the simplification of the enteral system into aunified gut compartment. The biotransformation and transport rates inthe model, being dependent on chemical entity structure, were estimatedby fitting the model to the plasma concentration time profiles of OCA,glyco-OCA, and tauro-OCA.

The PK model was first developed using the OCA, glyco-OCA, and tauro-OCAplasma concentration time profiles from healthy volunteers with normalhepatic function. Model parameter estimates related to healthyphysiology were then held constant while the PK model was furtherdeveloped using OCA, glyco-OCA, and tauro-OCA plasma concentration timeprofiles from patients with hepatic impairment (Child-Pugh scores A, B,and C). Only parameters specific to hepatic impairment were estimatedduring this process.

Four mechanisms of hepatic impairment were incorporated into the OCA PKmodel and included (1) reduction of hepatic uptake, (2) portal systemicshunting, (3) decreased functional volume, and (4) preferentialconjugation to taurine. These parameters were incorporated in the modelin a manner allowing the parameter estimates in subjects with mild,moderate, and severe hepatic impairment to progressively deviaterelative to the parameter values estimated in healthy volunteers. Thesedeviations for the portal systemic shunting and decreased functionalliver volume mechanisms used physiological values from the Simcyplibrary for cirrhotic subjects (SimCYP simulator Version 11; SimcypLimited, Sheffield, UK). The deviations for the reduced hepatic uptakeand change in OCA conjugation mechanisms were estimated based on fittingof the plasma drug concentration time profiles from subjects withhepatic impairment. Table 28 lists the model parameters and codingmodifications associated with the four mechanisms of hepatic impairment.

TABLE 28 Model Parameters and Coding Modification associated withmechanism of Hepatic Impairment. Anatomical/ Physiological ChangeEquations Decreased t_(10-Mild) = t₁₀ *exp(Effect in Mild hepaticimpairment hepatic in hepatic uptake of OCA and conjugates) uptaket_(10-Moderate) = t₁₀ *exp(Effect in Moderate hepatic impairment inhepatic uptake of OCA and conjugates) t_(10-Severe) = t₁₀ *exp(Effect inSevere hepatic impairment in hepatic uptake of OCA and conjugates)Portal- f_(4-Mild) = f₄*1.408 for mild hepatic impairment systemicf_(4-Moderate) = f₄*1.625 for moderate hepatic impairment shunting/f_(4-Severe) = f₄*1.915 for severe hepatic impairment Arterialf_(8-Mild) = f₈*0.91 for mild hepatic impairment buffer f_(8-Moderate) =f₈*0.635 for moderate hepatic impairment response f_(8-Severe) =f₈*0.554 for severe hepatic impairment Decreased V_(liver-Mild) =V_(liver-healthy)*0.891 for mild hepatic functional/ impairmentanatomical V_(liver-Moderate) = V_(liver-healthy)*0.71 for moderatehepatic liver impairment volume V_(liver-Severe) =V_(liver-healthy)*0.61 for severe hepatic impairment Changes inb_(16-Mild) = b₁₆* exp(Effect of Mild hepatic metabolism/ impairment onOCA tauro-conjugation) for mild conjugation hepatic impairmentb_(16-Moderate) = b₁₆* exp(Effect of Moderate hepatic impairment on OCAtauro-conjugation) for moderate hepatic impairment b_(16-Severe) = tb₁₆*exp(Effect of Severe hepatic impairment on OCA tauro-conjugation) forsevere hepatic impairment

For the portal systemic shunting mechanism, the coefficient for portalto sinusoidal flow was progressively decreased as hepatic impairmentworsened and was matched by a progressive increase in flow from theportal to systemic circulation of equal magnitude. The latter flow doesnot occur in healthy individuals. To compensate for reduced blood flowto the liver, the coefficient for hepatic arterial flow from thesystemic circulation to the sinusoids was progressively increased withworsening hepatic impairment (i.e., hepatic arterial buffer response).

The biotransformation coefficient for conjugation of taurine to OCA wasallowed to change for mild, moderate, and severe hepatic impairmentrelative to the coefficient in healthy subjects while the coefficientfor conjugation to glycine was fixed at the value for healthyindividuals.

The OCA physiologic PK model used a population PK approach and consistedof a description of the relationships between plasma drug concentrationsand time as well as components for between subject and residualvariability. Between subject variability (BSV) was modeled assuming alog-normal distribution as follows:

θ_(in)=θ_(TVn)exp(η_(in))

(ƒ₁ . . . η_(m))˜MVN(0,Ω)

Where θ_(TVn) is the population typical value for the n^(th) PKparameter (e.g., clearance) and η_(in) (ETA) is the random BSV on then^(th) parameter for subject i that jointly follow a multivariate normaldistribution (MVN) with a mean of zero and variance of Ω. The BSV modelassumes that PK parameters are log-normally distributed. Due to the highlevel of model complexity, BSV was only incorporated on K_(a) and theflow rate from gallbladder to gut, both parameters that analysis showedhad substantial impact on the plasma concentration time profiles.Residual variability was assumed to have additive and proportionalcomponents:

y _(ij) =ŷ _(ij)×(1+ε_(ij))+ε_(2ij)

Where y_(ij) and ŷ_(ij) represent the j^(th) observed and predictedplasma drug concentration for the i^(th) subject and ε is the randomresidual variability. Each ε is normally distributed with a mean of zeroand a variance of σ². Distinct residual variability components wereestimated for OCA, glyco-OCA, and tauro-OCA.

Model development was guided by feedback from various diagnostic plotsincluding: observed OCA, glyco-OCA, and tauro-OCA versus populationprediction (PRED) or individual prediction (IPRED) with a line of unityand trend line, conditional weighted residuals (CWRES) of OCA,glyco-OCA, and tauro-OCA versus PRED or time, and prediction-correctedvisual predictive checks (pcVPC; 200 iterations).

A simulation with 200 replicates was performed based on subjects in thephase 1 hepatic impairment study using the OCA physiologic PK model.Dosing and meal consumption history were used to simulate rich 0 to 216hour concentration-time profiles of OCA, glyco-OCA, and tauro-OCA. TotalOCA was calculated for each observation by summing the molar-basedconcentrations for OCA, glyco-OCA, and tauro-OCA. Total OCAconcentrations from the systemic circulation and liver were subjected tonon-compartmental analysis to calculate C_(max) and AUC_((0-216h)).

Phoenix® NLME™ software version 1.3 (Certara Inc., Princeton, N.J.) wasused for the physiologic population PK analysis and simulations withLindstrom-Bates First-order Conditional Estimation (FOCE-LB). Analysisdatasets, visualizations, and exploratory analyses were created using Rsoftware version 3.1 (The R Foundation) and SAS version 9.4 (SASInstitute Inc., Cary, N.C.). GraphPad Prism software version 6.07(Graphpad Software Inc., La Jolla, Calif.) was used for the generationof some graphical analyses.

The OCA physiologic PK model was initially developed using 8248 plasmasample concentrations of OCA, glyco-OCA, and tauro-OCA from 160 healthyvolunteers administered 10 mg OCA in a cross-over design. Each subjectcontributed PK samples from both study periods. The healthy volunteerpool had normal hepatic function, was primarily male (59%), mean (SD)age was 37.0 (9.8) years, and mean (SD) weight was 76.4 (11.8) kg.Volunteers were 65.6% white, 32.5% black, 0.6% Asian, and 1.3% other.The percentage of BLQ samples with imputed concentrations was 38.2%,9.4%, and 24.4% for OCA, glyco-OCA, and tauro-OCA, respectively.

The healthy PK model contained a total of 22 parameters: 7 flowparameters, 4 biotransformation parameters, and 11 transport parameters(Table 29). Many of these were expected to have values specific toexogenous OCA (e.g., hepatic uptake) or did not exist in the base model(e.g., K_(a) or K_(out)) and thus required estimation. Most of the flowparameters were fixed to physiological values from the literature withthe exception of bile duct to gallbladder and from bile duct to gut. Allstructural parameters (Table 29) were well estimated (≦5.5% CV). The BSVfor flow from bile duct to gallbladder was 78.1% (19.3% CV) and for theoral absorption of OCA was 195% (2.21% CV). The additive portion ofresidual variability was ≦1 nM (15-50% CV) and the proportional portionranged from 72% to 88% (30-70% CV) for OCA and its conjugates. The pcVPCresults shown in FIG. 25A, FIG. 25B, FIG. 25C, and FIG. 25D and thegoodness of fit plots shown in FIG. 18 and FIG. 19 indicate acceptablemodel performance.

TABLE 29 Model Parameters in Normal Hepatic Function BSV ParameterParameter Description Estimate CV % (RSE %) f₄ (L/h) Hepatic arterialflow 14.4 Fixed NA f₃ (L/h) Hepatic portal flow 39.6 Fixed t₁₀ (h⁻¹) OCAtransport rate from 1698 1.0 liver to sinusoidal space t₉ (h⁻¹)Glyco-OCA transport rate 1210 2.0 from sinusoidal space to liver t₁₁(h⁻¹) Tauro-OCA transport rate 1615 1.9 from sinusoidal space to livert₁₃ (h⁻¹) OCA transport rate from 1.62 Fixed sinusoidal space to livert₁₂ (h⁻¹) Glyco-OCA and tauro-OCA 1.62 Fixed transport rate from liverto sinusoidal space f₂₄ (L/h) Flow from bile duct to gut 7.29 4.5 f₂₂(L/h) Flow from bile duct to 0.856 4.4 78.1% gallbladder (19.3) f₂₃(h⁻¹) Rate of output from 1.2 Fixed NA gallbladder to gut k_(out) (L/h)Rate of fecal elimination 0.612 5.5 of OCA b₁₅ (h⁻¹) OCA rate ofconjugation 1.44 4.5 with glycine b₁₆ (h⁻¹) OCA rate of conjugation0.312 1.9 with taurine b₃₆ (h⁻¹) Glyco-OCA rate of 0.0431 4.5deconjugation to OCA b₃₇ (h⁻¹) Tauro-OCA rate of 0.0200 1.8deconjugation to OCA t₃₄ (h⁻¹) OCA rate of absorption 0.857 3.4 from gutto portal space t₃₃ (h⁻¹) Glyco-OCA rate of 0.904 1.1 absorption fromgut to portal space t₃₅ (h⁻¹) Tauro-OCA rate of 1.62 2.2 absorption fromgut to portal space K_(a) (h⁻¹) OCA first order rate 5.32 1.0 195%constant of oral (2.21) absorption t₁₉ (h⁻¹) Glyco-OCA transport rate7.44 0.7 NA from liver to bile duct t₂₁ (h⁻¹) Tauro-OCA transport rate9.28 1.0 from liver to bile duct Proportional Error OCA (%) 88.0 33.9 NAProportional Error Glyco-OCA (%) 62.6 32.7 Proportional Error Tauro-OCA(%) 71.6 70.4 Additive Error OCA (nM) 0.546 16.5 Additive ErrorGlyco-OCA (nM) 0.675 21.8 Additive Error Tauro-OCA (nM) 0.469 50.3

Development of the PK model for the physiological changes associatedwith hepatic impairment used 928 plasma sample concentrations of OCA,glyco-OCA, and tauro-OCA from 32 subjects-8 subjects each with mild,moderate, severe hepatic impairment and normal hepatic function.Subjects were administered a single 10 mg dose of OCA. The studysubjects were primarily male (72%), had a mean (SD) age of 55.0 (5.6)years, and mean (SD) body weight was 81.7 (16.9) kg. Participants were90.6% white, 3.1% black, 3.1% Asian, and 3.1% other. Mean Child-PughScore was 8.0 (2.0) (Child-Pugh Score: Class A/Mild 5-6 points, ClassB/Moderate 7-9 points, Class C/Severe 10-15 points). The percentage ofBLQ samples with imputed concentrations was 16.8%, 5.4%, and 9.6% forOCA, glyco-OCA, and tauro-OCA, respectively.

The 22 PK parameters from the healthy PK model were held fixed duringthe development of the model for hepatic impairment. Portal systemicshunting and reduced functional liver volume parameters were fixed tophysiological values from the literature while parameters associatedwith reduced hepatic uptake and changes in OCA conjugation wereestimated. Parameter estimates for hepatic uptake and taurineconjugation obtained from the hepatic impairment PK model are presentedin Table 30. The structural parameters were well estimated (<25% CV)with the exception of the change in hepatic uptake in OCA and itsconjugates in moderate hepatic impairment (44% CV) and the change in OCAconjugation for severe hepatic impairment (109% CV). The BSV for flowfrom bile duct to gallbladder was 168% (299% CV) and for the oralabsorption of OCA was 246% (9.87% CV). The additive portion of residualvariability was ≦1 nM (>75% CV) and the proportional portion ranged from112% to 123% for OCA and its conjugates (>75% CV). This magnitude ofvariability is consistent with a bile acid analog that undergoesextensive enterohepatic recirculation. The pcVPC results shown in FIG. 2and the goodness of fit plots indicate acceptable model performance.

TABLE 30 Modified Model Parameters in Impaired Hepatic FunctionParameter Estimate CV % Effect in Mild hepatic impairment in −0.132 9.11hepatic uptake of OCA and conjugates Effect in Moderate hepaticimpairment in −1.86 44.3 hepatic uptake of OCA and conjugates Effect inSevere hepatic impairment in −2.37 24.9 hepatic uptake of OCA andconjugates Effect of Mild hepatic impairment on OCA 0.00481 0.341tauro-conjugation Effect of Moderate hepatic impairment on 1.05 15.8 OCAtauro-conjugation Effect of Severe hepatic impairment on 1.56 109 OCAtauro-conjugation Proportional Error OCA (%) 122 77.1 Proportional ErrorGlyco-OCA (%) 112 384 Proportional Error Tauro-OCA (%) 123 636 AdditiveError OCA (nM) 0.993 77.1 Additive Error Glyco-OCA (nM) 0.273 383Additive Error Tauro-OCA (nM) 0.532 627 BSV OCA first order rateconstant of oral 246% 9.87 absorption Flow from bile duct to gallbladder168% 299

The final OCA physiologic PK model, developed for both normal andimpaired hepatic function, was validated with external PK data insubjects with normal (single doses of 10 mg and multiple-dosing tosteady-state with doses of 5 mg, 10 mg, or 25 mg) and hepatic impairment(cirrhosis and portal hypertension). FIG. 27A to FIG. 27C and FIG. 28Ato FIG. 28C show pcVPC-based assessments of the models ability toaccurately predict the plasma total OCA concentration time profilesunder these varied conditions. The model predicted the profiles well forsubjects with normal hepatic function (FIG. 20, FIG. 21) and forsubjects with moderate or severe hepatic impairment (FIG. 22). For mildhepatic impairment, the model tended to underestimate the total OCAconcentrations.

Simulations of total OCA in the systemic circulation (plasma) and in theliver after a single 10 mg dose were compared to observed total OCAplasma concentrations from the hepatic impairment clinical study in FIG.23. The total OCA exposures are summarized as either the C_(max) or theAUC over the 216 hour sampling period. For both exposure measures, andacross all levels of hepatic function, there appeared to be agreementbetween the exposures observed in the clinical trial and the exposurespredicted by the PK model. Simulation data in Table 31 reveals that thesystemic AUC of total OCA in subjects with mild, moderate, and severehepatic impairment increased 1.4-, 8.0-, and 13-fold relative tosubjects with normal hepatic function. However, in the liver, thepredicted AUC of total OCA in subjects with mild, moderate, and severehepatic impairment increased only 1.1-, 1.5-, and 1.7-fold relative tosubjects with normal hepatic function

TABLE 31 Systemic AUC of total OCA in Patients with mild, moderate, andsevere hepatic impairment. Liver Impairment Ratio (LiverImpairment/Normal) Exposure Metric Normal Mild Moderate SevereMild/Normal Moderate/normal Severe/normal Systemic AUC (ng × h/mL) 23393156 18785 30986 1.35 8.03 13.2 C_(avg) (ng/mL) 10.8 14.6 87 143 1.358.03 13.2 C_(max) (ng/mL) 99.5 131 634 961 1.31 6.38 9.66 Liver AUC (ng× h/mL) 47427 53032 69540 82521 1.12 1.47 1.74 C_(avg) (ng/mL) 220 246322 382 1.12 1.47 1.74 C_(max) (ng/mL) 2395 2665 2701 2651 1.11 1.131.11 Mean Simulated OCA Distribution (% Nanomoles Total OCA) SystemicCirculation 1.03 10.36 Portal Circulation 0.77 2.33 SinusoidalCirculation 0.05 0.45 Liver 7.88 10.44 Bile Ducts 0.14 0.13 Gallbladder39.94 37.74 Gut 50.20 38.56

This OCA physiologic PK model, derived from prior bile acid models,provides valuable insights into the absorption, distribution,metabolism, and excretion of the drug. Orally administered OCA isabsorbed from the intestines, conjugated with glycine or taurine in thehepatocyte, and the conjugated OCA circulates enterohepatically.Conjugation also results in most of the OCA conjugates being poorlyabsorbed in the proximal small intestine and reaching the terminalileum, where bile acids are actively conserved. The predominantpharmacodynamic activity of OCA is thus mediated by its taurine andglycine amidates in the hepatocyte and distal small intestine.

The PK model used a dosing compartment and first-order rate constant(K_(a)) to represent the cumulative processes from oral intake of OCAthrough entry into the gut. The population mean half-life for thisprocess was 0.13 hours, but the high BSV on K_(a) indicated that theabsorption process varied substantially between subjects. Once in thegut, the model estimated the extent of intestinal absorption for OCA atapproximately 56%. This value is likely an underestimation due toconsolidation of the various segments of the small and large intestineinto a single gut compartment wherein OCA gets absorbed and excretedfrom the same compartment. The extent of intestinal absorption forglyco-OCA and tauro-OCA was 95% and 99%, respectively. Simulations forhealthy subjects using the PK model showed that at steady-state, ˜90% oftotal OCA mass is distributed to the gut and the gallbladder.Approximately 8% of the total OCA mass resides in the liver while ˜1%can be found in the plasma of the systemic circulation. In contrast, thesimulated total OCA mass increases to ˜10% in the systemic circulationin patients with Child-Pugh C hepatic impairment with the liverdistribution being approximately equal to healthy subjects (˜10%). Thesimulated gut and gallbladder distribution was 79% in patient withChild-Pugh C hepatic impairment. The low systemic levels of total OCAwould in part explain the high variability observed in plasma.

The PK model estimated hepatic uptake, in healthy subjects, at 79%, 73%,and 78% for OCA, glyco-OCA, and tauro-OCA, respectively, are consistentwith hepatic uptake values reported for CDCA. Once in the liver, OCA wasconjugated to glycine and taurine in a ratio of 4.6:1, consistent withthe normal range for endogenous bile acids. Simulations from the PKmodel showed that the half-life for OCA is approximately 4 daysindicating a time to steady-state or a post-treatment washout period ofabout 2 weeks. The estimated OCA half-life is consistent with thehalf-life values for CDCA reported in the literature.

Simulations using the PK model predicted changes in systemic and liverOCA concentrations associated with changes in the severity of hepaticimpairment. Model simulations predicted that for mild, moderate, andsevere hepatic impairment, total OCA concentrations in the plasmaincrease 1.4-, 8.0-, and 13-fold relative to subjects with normalhepatic function while total OCA concentrations in the liver increase1.1-, 1.5-, and 1.7-fold, respectively. The predicted changes in plasmaOCA concentrations were similar to the observed concentration of totalendogenous bile acids in subjects with alcoholic cirrhosis. Theconcentration of total endogenous bile acids measured in the plasma wereincreased 1.6-, 6.4-, and 13-fold for mild, moderate, and severe hepaticimpairment relative to normal hepatic function, respectively.Previously, soluble and tissue-bound hepatic bile acids were measured byFischer et al. from the livers of end-stage liver disease patients andcompared to measurements made from healthy livers (resected for tumorsbut functionally and histologically normal). It was shown thatendogenous bile acid levels in the serum of patients with end-stageliver disease prior to liver transplantation were 18-fold greater thanthose in healthy subjects; however, in the livers from patients withend-stage liver disease bile acid levels were only approximately 2-foldhigher relative to healthy livers. The observed 2-fold increase in theliver exposure of endogenous bile acids is in good agreement with thepredicted increase in total OCA exposure in subjects with severe hepaticimpairment (1.7-fold; Child-Pugh C). These results suggest that the PKcharacteristics of OCA are very similar to endogenous bile acids.

There were some differences between the observed and predicted values inthe external validation in patients with mild hepatic impairment. TheChild-Pugh score is based on total bilirubin, serum albumin, prothrombintime, ascites, and hepatic encephalopathy. While all of these parametersare indicators of prognosis in liver disease, they do not allnecessarily reflect substantial changes in PK or flow mechanicsin/around the liver. Without being bound by any particular theory, thepresence of portal hypertension in the validation cohort for mildimpairment may be a reason for a discrepancy between predicted andobserved values in patients with mild hepatic impairment.

The OCA physiologic model predicted liver to plasma ratios for OCAconcentrations that were similar to the ratios previously observed forendogenous bile acids. These results indicate that the liver to plasmaratio is not consistent between healthy subjects and patients withhepatic impairment. The liver is the primary site of action for thesafety and efficacy of OCA; therefore, it is important to account forthe differences in systemic and liver exposure when assessing aneffective dose. The hepatically-impaired patients treated with OCAexperienced plasma OCA exposures >10-fold higher than those experiencedby healthy subjects, yet there was no apparent impact on the overallsafety profile experienced by these patients. The safety results areconsistent with only a modest increase in liver exposure of OCAassociated with hepatic impairment. Collectively, the results from theseanalyses and those from literature for bile acids would suggest that thedose of OCA administered to hepatically-impaired patients should bemodestly lower than those for patients with normal hepatic function toachieve similar hepatic exposure.

Example 12

This example describes a clinical, double-blind study examining theeffect of daily 25 mg OCA on nonalcoholic steatohepatitis (NASH). OCAlead to biopsy proven improvements in liver fibrosis. Patients with NASHwho have elevated NAFLD activity scores (NAS) and fibrosis are at ahigher risk of progression to cirrhosis and liver related mortality.

The high risk subgroup was defined as patients with a baseline NAS≧4,baseline fibrosis stage 2 or 3 or baseline fibrosis stage 1 with acomorbidity (type 2 diabetes, BMI≧30 kg/m² or ALT≧60 U/L) (OCA n=114;Placebo n=112). The Fibrosis-4 (FIB-4), the aspartate transaminase toplatelet ratio (APRI), and the NAFLD fibrosis score (NFS) were allexamined between baseline through 72 weeks of treatment and for anadditional 24 weeks of follow up.

Significant reductions were observed as early as week 24 and persistedthrough the course of treatment. Patients receiving OCA had significantimprovements compared to placebo in all three non-invasive measures offibrosis at week 72 (FIB-4 OCA-Placebo LS Mean change=−0.33, 95%CI=[−0.47, −0.19], p<0.0001; APRI OCA-Placebo LS Mean change=−0.23, 95%CI=[−0.32, −0.15], p<0.0001; NFS OCA-Placebo LS Mean change=−0.28, 95%CI=[−0.45, −0.10], p<0.01). However, 24 weeks after concludingtreatment, all three scores had diminished improvement and trendedtoward baseline values.

Treatment with OCA lead to significant early and sustained improvementsin FIB-4, APRI, and NFS in patients in a subgroup at higher risk forliver related mortality in NASH. However, without OCA, improvement inthese non-invasive measures of fibrosis diminished, possibly due tocontinuing underlying disease pathogenesis.

1. A composition comprising obeticholic acid, or a pharmaceutically acceptable salt, ester, or amino acid conjugate thereof, wherein obeticholic acid or a pharmaceutically acceptable salt, ester, or amino acid conjugate thereof is in the form of particles, and wherein at least 50% of the particles have a diameter of 200 μm or less.
 2. The composition of claim 1, wherein at least 50% of the particles have a diameter of 100 μm or less.
 3. The composition of claim 2, wherein at least 50% of the particles have a diameter of 50 μm or less.
 4. The composition of claim 3, wherein at least 50% of the particles have a diameter of 10 μm or less.
 5. The composition of claim 4, wherein at least 50% of the particles have a diameter of 5 μm or less.
 6. The composition of claim 1, wherein at least 90% of the particles have a diameter of 200 μm or less.
 7. The composition of claim 6, wherein at least 90% of the particles have a diameter of 100 μm or less.
 8. The composition of claim 7, wherein at least 90% of the particles have a diameter of 25 μm or less.
 9. The composition of claim 1 further comprising at least one pharmaceutically acceptable excipient having an alcohol content of less than about 6% (wt/wt).
 10. The composition of claim 9, wherein the at least one pharmaceutical acceptable excipient is sodium starch glycolate.
 11. A tablet comprising an intra-granular portion and an extra-granular portion, the intra-granular portion comprising obeticholic acid, or a pharmaceutically acceptable salt, ester, or amino acid conjugate thereof, microcrystalline cellulose, and one or more additional pharmaceutical excipients, and the extra-granular portion comprising one or more pharmaceutical excipients.
 12. The tablet of claim 11, wherein the extra-granular portion comprises microcrystalline cellulose.
 13. A method for preparing a composition comprising obeticholic acid, or a pharmaceutically acceptable salt, ester, or amino acid conjugate thereof, in the form of particles, wherein at least 50% of the particles have a diameter of 200 μm or less, comprising forming the particles through jet-milling.
 14. A method of treating primary biliary cirrhosis (PBC) in a patient in need thereof, said method comprising administering a composition comprising an effective amount of obeticholic acid, or a pharmaceutically acceptable salt, ester, or amino acid conjugate thereof, wherein obeticholic acid or a pharmaceutically acceptable salt, ester, or amino acid conjugate thereof is in the form of particles, and wherein at least 50% of the particles have a diameter of 200 μm or less.
 15. A method of treating a condition selected from the group consisting of primary sclerosing cholangitis (PSC), chronic liver disease, nonalcoholic fatty liver disease (NAFLD), nonalcoholic steatohepatitis (NASH), hepatitis C infection, alcoholic liver disease, liver damage due to progressive fibrosis and liver fibrosis in a patient in need thereof, said method comprising administering a composition comprising an effective amount of obeticholic acid, or a pharmaceutically acceptable salt, ester, or amino acid conjugate thereof, wherein obeticholic acid or a pharmaceutically acceptable salt, ester, or amino acid conjugate thereof is in the form of particles, and wherein at least 50% of the particles have a diameter of 200 μm or less.
 16. The method of claim 15, wherein said condition is nonalcoholic steatohepatitis (NASH).
 17. The method of claim 14, wherein said method further comprises administering said obeticholic acid composition as a starting dose.
 18. The method of claim 17, wherein said starting dose is administered in a titration period.
 19. The method of claim 18, wherein said titration period comprises 1 to 6 months.
 20. The method of claim 18, wherein said titration period is 3 months.
 21. The method of claim 18, wherein said titration period is 6 months.
 22. The method of claim 18, wherein said starting dose is administered to said patient once daily.
 23. The method of claim 18, wherein said starting dose is administered to said patient once weekly.
 24. The method of claim 18, wherein said starting dose is administered to said patient once every other day.
 25. The method of claim 14, wherein said composition comprises obeticholic acid in an amount of about 1 mg to 50 mg.
 26. The method of claim 25, wherein said amount is about 1 mg to 25 mg.
 27. The method of claim 25, wherein said amount is about 1 mg to 10 mg.
 28. The method of claim 14, wherein said composition comprises about 5 mg obeticholic acid.
 29. The method of claim 14, wherein said composition comprises about 10 mg obeticholic acid.
 30. The method of claim 14, wherein said composition comprises about 25 mg obeticholic acid.
 31. The method of claim 25, wherein said amount is about 50 mg.
 32. The method of claim 17, wherein said starting dose comprises about 5 mg.
 33. The method of claim 32, wherein said starting dose is adjusted to about 10 mg after a titration period of about 1 to 6 months.
 34. The method of claim 14, wherein the method further comprises administering a bile acid binding resin at least 4 hours before administration of the composition.
 35. The method of claim 14, wherein the method further comprises administering a bile acid binding resin at least 4 hours after administration of the composition.
 36. The method of claim 14, further comprising administering ursodeoxycholic acid to the patient.
 37. The method of claim 14, wherein the patient is not responsive to treatment with ursodeoxycholic acid. 